Tag Archives: SMS

Are “Passenger Lithium-ion Batteries” the same as “Cargo Lithium-ion Batteries?”

Captain Paul Miller preparing for a coming storm.

Captain Paul Miller preparing for a coming storm.

Recent passenger jet fires involving B787 Dreamliner have made news, but is it really new news? FAA and other regulators have dismissed the dangers of lithium-ion batteries when carried on cargo aircraft because. Why? Well, perhaps it is because fires on on cargo airline aircraft result in “no significant loss of life?” Isn’t this the legal reasoning offered by aviation officials when safety issues concerned cargo airline flights and not passenger airlines? That is right, cargo companies are called cargo airlines and operate under much the same rules as passenger carrying airlines.

But when a recent fatigue law was ruled not applicable to cargo airlines, thus cargo pilots, again by these same aviation officials, cargo pilots cried out, “Not fair to us!”

What they should have cried out should have been, “Not fair to the flying public!”

Yes, this ruling carved out an exemption from all sorts of safety rules for cargo airlines by aviation officials, from the same rules that will govern passenger carrying airlines. What I am arguing is this “carving out”process by aviation officials could well be seen as quite unfair to the flying public. How so you might ask?

Here are several examples. In 2006, lithium-ion batteries carried as cargo on a cargo airline caught fire in the air. A crew was hospitalized after they barely got the jet on the ground, that same aircraft finally being total destroyed by that fire.  The crew had to jump out of  cockpit windows to escape a burning smoke-filled aircraft.  Then again, four years later two cargo airline crews were not so lucky. In both of those cases in 2010 the fires were so quick moving and so intense, that despite their best efforts,  the crews of both aircraft perished in the fires while still in the air and then the cargo aircraft crashed.

Once again however, aviation officials, in a show of unprecedented irony, ascribed the events to cargo airlines and therefore not a passenger airline issue. Strangely enough however, the one common thread in these three stories are the batteries, the lithium-ion batteries. In each case, the batteries carried as cargo caught fire in the air and then caused massive fires inside the airplanes.  Despite the three known fires investigated by aviation officials, despite warnings going back to 2006 that these lithium-ion batteries can be very unsafe to carry in the air, these same aviation officials approved the use of these same batteries on the B787 Dreamliner. Not only was the approval for carriage of the batteries, but the approval was to hook up the batteries to the aircraft electrical system as electrical power sources, meaning that on every flight of a B787, there would be large lithium-ion batteries aboard and connected.

Many people would ask why this was done and why it was allowed to be done? My guess, and it is only a guess is that most likely, battery manufacturing experts explained to some aviation official lawyers, that these are somehow different batteries and different battery applications than those involved in the three cargo aircraft destructive mishaps. On paper, on a slide presentation in front of a room of officials, that argument probably, and obviously,  played well.

But in the end, the question remains now in the front of the minds of the public and press, “Are ‘Passenger Airline Lithium-ion Batteries’ the same as ‘Cargo Airline Lithium-ion Batteries’?” The events surrounding recent B787 lithium-ion battery related fires seems to raise serious questions about that question.

Maybe time and science and engineering will show us that this gendre of lithium-ion batteries can be made safe for the skies. That would be preferable for the future of the battery industry and the airline industry. But for right now, the question seems to be that they are similar enough in their fire catching characteristics to make all us in safety quite concerned?

Maybe these same aviation official lawyers can reconsider whether cargo pilots are somehow less susceptible to fatigue than passenger pilots and rescind the cargo carve out of the most recent fatigue rulings.100_3985 For it is in this transgression of logic that B787 Dreamliners took to the skies with lithium-ion batteries that may be the same type of batteries that brought the first of three cargo airline aircraft to destruction more that six years ago.

Safety versus Everything Else not SMS

Safety Managers can sort through legalities by remembering what safety is and what safety is not. Safety is about prevention, human factors, reporting and investigating, fixing the problem, communicating and looking forward.

Safety is not about criminal law, civil law, administrative law or regulatory law; it is not about public administration or zoning around airports. It is not about public relations, disaster preparedness and actually, much to the surprise of many, it is not about accident investigation.

All of these subject areas may involve commercial aviation and we have to be about the business of managing all of these areas, but they are not safety management.

Safety management is now going through the SMS phase and that is mostly good. But there is a mystic which may confuse some, turn off others or gray the black and white lines of aviation safety.

Safety must foremost be prevention, prevention of hazards from becoming mishaps. Strong leadership in safety is needed to make prevention happen; it does not come naturally to us humans to prevent mishaps, we tend to trip and skin our knees, we do not always seem ready to prevent the trip and fall. But prevention is cheaper. Straightening a rug by a door is cheaper that sending a guest to the hospital with a trip caused broken bone.

Safety is really all about human factors or what we really know as human error. There is no mishap on record that did not hold human error to account. So prevention really does seem to be a human error issue, what can we do as flight crew to improve our human performance. Training comes to mind, procedures and checklists as part of that.

Safety is all about the reporter finding a hazard and yelling out loud, “Hey, here is a problem everyone!” Those of us gifted to see thing may see more, but everyone sees something. Encourage reporting.

Fixing the problem is critical, don’t just report the hazard. There is no one other than the safety manager who is more in charge at this point; this is your time to shine. Do the work corporately or by your own imagination- but get the work done to find the solution and pronto. Remember that the flight on which the hazard was found will be repeated in an hour, a day or a week. No time for waiting for “the system to work.” The system didn’t work and now is the time to step in and take action, work with others to take action, manage others who are taking action or foster the action takers to hurry up.

Communicating is how safety works. Remember that you both speak for the pilots and to the pilots. They speak to you. Keep those channels open and flowing. Do whatever is needed in your organizations culture to encourage communications. Remember also that Tweets, emails, Facebook, IM’s and every new electronic media is whats happening now.

Lastly, safety is all about looking forward to mishap free operations.  Consider everything you do as influencing a safer tomorrow. You will be one of the few who do.

Remember, do not get involved, sidetracked or distracted by what safety is not. As the safety manager, you are the only one doing those six safety goals leading you to the now SMS.

Alone in the sky with the sunrise.

Alone in the sky with the sunrise.

Safety Purpose vs the Legal Purpose: Why the Safety Purpose Works: are you looking and leading forward or backward?

Safety Purpose vs the Legal Purpose: Why the Safety Purpose Works: are you looking and leading forward or backward?

The Safety Purpose seeks the cause of mishaps and tries to determine procedures to immediately and forever prevent a re-occurrence. The Legal Purpose on the other hand attempts to find fault or blame for injury and damage and assign penalties.

But there is one other very significant characteristic that safety managers need to know in order to do their job successfully, to be winners and lead their organization into a mishap free future. Here it is in a nutshell:

Lawyers only look backwards in time, never forward. When a lawyer says, “The ice crystal icing is new,” what he/she really means to communicate with you is that this subject area before has never shown up in court previously in a negligence case. There is no case history of this type of event.” We have recently heard a statement similar to this in AF 447 reports.

The event of ice crystal formation around the clouds of very tall thunderstorms is as old as the natural history of the earth, that is tens of billions of years old. Scientists of meteorology physics have shown us this in lab experiments and field observations. Teachers of pilots have been warning students to not only stay out of thunderstorms, but to say away from the high overhang of the upper clouds as well. This is nothing “new,” and pilots who desire to have a long career have paid heed to this advice for decades.
This is a good example of why lawyers running safety programs is a flawed concept. In law school, lawyers are taught to only look backwards.

THE SAFETY PURPOSE on the other hand, looks forward. Safety looks forward toward accident reduction, toward hazard resolution and the huge financial savings of mishap-free flight operations. So safety was achieved in flight school by educating pilots in the future to stay clear of thunder storms and avoid the overhangs. Not only can the ice crystal threat of the overhang be a hazard, but often hail showers can be located in these areas.

The flaws in the fostering of the Safety Purpose at BEA, AF, AB and other organizations such as FAA may very well be rooted in this very basic differential theory of management.

It is my opinion that the forward view found in SAFETY THEORY is of much more value to the commercial airline industry that the Legal Theory of finding fault and assigning penalties.

My guess is that airlines with safety people in charge of safety programs do a heck of a lot better than those with lawyers trying to run things. My guess is that the safety people at the regulatory authorities do a daily, albeit losing battle with the attorneys that have taken over positions of upper management.

JMHO, of course.

Is Safety Guilding the Lily or Is Safety Making Necessary Operational Improvements?:Who has the better argument?

I think that we have to rethink this logic ladies and gentlemen. Safety recommendations do one very special thing that no other recommendation does. Safety recommendation give us SOP modifications, checklists and limitations that help us to do our operation more correctly.

Some of you may say, “Don’t you mean more safely?”

I would respond by saying, “No, not more safely, but more correctly.” Why? Remember that our stated goal in all operations is safety-not 90% safety but 100% safety.

So when we figure out how to do operations safer, it is really most often soon adopted as SOP. Safety finds new and better ways to operate and then training, ops and standardization offices figure out how to turn that “safety innovation” into a New SOP, limit or checklist.

Right? Isn’t our SOP being revised all the time? Aren’t our Jeps procedures being revised regularly? Do we not see constant improved regulations all the time?

Did all of these improvements in SOP, Jeps, limits, regs really cost us all that much money? How much money did we waste to mishaps using flawed SOP’s?

So Safety is not as expensive as some would try to make us believe. In fact, more often than not, safety has reduced our costs, reduced our expenses, make our operation more correct, effective and greatly more efficient.
Remember the sight of the Delta L1011 crash in Dallas on the front page of the papers? Remember the United DC 10 crash in Sioux City all over every TV stations for weeks? Look at Tenerife, a classic air tragedy. Look at TWA 800; all over the news for months. Look at the dozens and dozens of microburst related mishaps and the hundreds of dead.

Safety helps us to do our job better. Do those that claim that “safety is guilding the lily” with unnecessary and expensive changes really have a case?

Does their argument really “hold water?” In fact hasn’t safety made our operations more correct?

Cost and Benefit Analysis vs Successful Safety Programs: Is the FAA and A4A Using Flawed Logic to Manage Safety Improvements? Do Pilots Actually Know Safety Better?

Air Transport Association (ATA), or now Airlines for America (A4A) and the FAA can not claim all of the credit for the huge improvement in airline safety over the last decade in my opinion. As a matter of fact and record, both the FAA and ATA now A4A, opposed, and opposed with great vigor, virtually every safety of flight recommendation from pilot groups and pilot associations, from individual pilot recommendations directly to the FAA and/or the employer company, from the NTSB and from just about every safety foundation, association and organization, not just in the last decade, but in the rememberable history of this writer. It has only been after sustained high levels of Washington lobbying, high profile professional papers delivered, public relations campaigns and other dedicated efforts that the FAA has agreed to any safety regulatory or legislative improvements and on the part of commercial companies, after very tough pilot associations legal negotiations for contractual safety improvements.

Examples? Collision Avoidance Systems (TCAS) for Cargo, Flight Duty and Rest Regulations, Improved Flight Crew  Training Requirements, Cockpit Smoke Equipment, improved security, higher ATC standards for aircraft handling and routing around severe convective weather, Aircraft Rescue and Firefighting (ARFF), Crash Fire and Rescue (CFR) at airport equipment and manning requirements and training, hazardous materials air cargo handling rules, regulations and laws.

Again, these are but a few of the many safety improvements worked for by commercial pilot associations, pilot trade groups, as well as various global flight safety oriented foundations.

Now let’s talk ASAP, the Aviation Safety Action Program. The joint commercial pilot working group worked 1993 to Sept 1995 on the Proposed Draft FAA Advisory Circular for Airline ASAP, based on the prototype successful program established by American, Allied Pilots Assn and the FAA Southwest Region. The FAA however sat on that AC, until publishing their first draft in Oct 1998 . The Final ASAP Advisory Circular appeared I believe in 2001. Many airlines then fought ASAP participation until finally agreeing and adopted ASAP in the mid 2000’s, fully ten years after it was recommended.

So I would challenge anything stated about safety by the FAA and A4A in terms of their advocacy and management thereof. In fact the FAA and A4A opposed ASAP and virtually all of these safety programs that eventually became very valuable programs.  Could it be argued that FAA and A4A are anything but an impediment to airline safety?

Oh, one more important point. All of the safety recommendations made by pilot associations and adopted as regulation, rule or law, have worked!!  I would argue that this is why the commercial airline industry is safer today than 10 years ago. That is why we are safer today than ten years ago, not because the FAA and A4A have argued the supposed “Cost and Benefit Analysis” at every safety program proposed.

It is my opinion that lawyers for the FAA and A4A have used “Cost and Benefit Analysis” in some cases to delay safety programs and have not, in so doing, protected the industry from costs. Quite the opposite is true in my opinion. This delay may have actually led to repeated human factorsmishaps of the same type being suffered throughout the industry again and again without resolution.

These costs related to commercial aviation disasters have wreaked financial havoc in the commercial airline industry by allowing hundreds of millions of dollars and hundreds of lives to be wasted, while substituting legal wrangling and administrative procedures to take precedence over safety.

For safety, look to the person with a personal stake in the argument and improvement.  Do not look to the supposed “Cost Benefit Analysis” argument for any value in safety.

More Questions Asked by Flight Crew Members Regarding AF 447

More questions have been raised by fellow safety minded pilots regarding AF Flight 447. Here are several:

1. Why were they flying through that nasty convective weather?

2. Why did the captain leave the cockpit just prior to the flight’s arrival to this area?

With respect to the questions asked, here is my take.

1. The captain had at least a 2 hour-old satellite pix by the time he started engines. The thunderstorm encounter occurred somewhere after about the second or third hour of flight, meaning that the AF 447 entered the thunderstorm area about four to five hours minimum after the satellite picture was taken. This means that it is very possible that the satellite picture that the captain received did not resemble the convective weather area that the flight eventually encountered enroute. This is assuming of course that the crew got a satellite pix at all out of Rio.  This is a very common pre-flight briefing problem for all airlines operating oceanic flights. Making the problem worse is that Flight Control is not required to resend the latest satellite shots to the crew during the flight.  Why is that? Why do we have rules that not only do not provide important weather information, but do allow the provision of somewhat inaccurate weather information? Why is that?

A. Let’s say that the captain was a cautious fellow and planned well. So he gets up a few hours before the hotel pickup, has a shower, checks his email, gets packed, dressed and meets the crew in the lobby. At the airport or maybe even at the hotel, he sees the satellite picture prepared and sent by AF Flight Control Dispatch Offices.

I have not seen a satellite pix or a weather observation from the time from 4-5 hours before the mishap, but if I was investigating this incident, that is the first place that I would look. Why? Well satellite picture is the information that will inform the captain as to what lies ahead of him and will inform his game plan, sleep strategy, crew switch strategy for the flight.  So my money is on a sat shot that shows widely scattered storms if any at all given to the captain during pre-flight briefings. He doesn’t see a threat at this time and doesn’t see any reason not to use his normal strategy of getting the oceanic clearance, getting the plane out onto the transoceanic tracks and then retiring to get some rest, letting the other crew members handle the routine of the crossing. This will allow him to get some sleep and be fresh when they get close to Europe and have to start their let down at CDG for landing. Maybe this is his normal routine. Based on this supposed scenario, it is a reasonable one.

B. Alternative scenario: The captain is a “show me” kind of guy; unless he sees the lightning flashes and is face to face with a thunderstorm, he doesn’t worry about the metro stuff, because it is all 4-5 hours old data by the time they get out onto the tracks for crossing.

Either way, I do not think that the captain foresaw that 60,000 ft+ inter tropical convergence zone storms in his path would be a real possibility.

Additionally, we might consider this: thunderstorms anywhere rise rapidly in height, developing at 2000-4000 feet per minute, even as much as 6000 feet per minute. Therefore, information such as “the previous flight got through this path” is not really all that valid information for following flights, especially flights following 10 to 15 minutes later.  The fact that another flight transited this area 10-15 minutes prior is certainly and in my opinion most definitely not an endorsement for safe flight in an area of active thunderstorm activity. Thunderstorms by their very nature are unstable. That is  what makes them so dangerous to flight. Thunderstorms violate the very first principle of aerodynamics, which says, “assume a homogeneous airmass.”  For sure a thunderstorm is not a homogeneous airmass!

Thunderstorm development in the inter-tropical convergence zone (ITCZ) is even more dynamic than at other places on the globe. This means that even more caution needs to be exercised in the ITCZ by commercial airline operations. Yet remember that this mishap occurred on a flight planned and operated regularly in the ITCZ by this airline.

C. Third scenario is this. This is the kind of fellow that does his own thing. He does the takeoff, then he does his nap, then he does his arrival. This is the way that he does things and this is his thing.  This is how he does every oceanic flight and he figures the other crew can handle things.  That is just the way he is.

D. Fourth possible scenario: The Air France Dispatch Office in CDG does not consider it their responsibility to update Air France flights with Air France passengers on board of dangerous weather that has developed and is now in the path of an Air France flight. They consider it their responsibility only to get the pre-flight paper work prepared and delivered and then do no further duties other than to stay awake and answer any questions that come up during the flight.

 

My guess is that AF Dispatch Flight Control Standard Operating Procedure SOP is not to initiate any inflight communications unless directed to do so by “higher authority” or some similar version of that idea. The second place that I would look were I doing the BEA investigation would be the AF Flight Control Log for AF 447, the AF Flight Control SOP and all of the metro data that was available to AF Flight Control before the mishap.

I would further examine just exactly how AF Flight Control does business every day and night with respect to how much info is passed to airborne flights concerning dangerous weather occurring ahead of any AF flight.

Sorry to say this but more than a few commercial flight crew members are like B and C. I am even more sorry to say that more often than not, many flight control offices are like D. They send company flights on flight paths that intersect dangerous weather and do not change plans along the way. My guess is that this most likely remains “the way things are” at many airlines. How about yours? Are you in a position to make some changes at your airline?

So that is some thoughts on question one. But if you are a good captain and a good communicator, my guess is that you also have a few ideas and I would be very interested in hearing from you and reading your thoughts on this same question.

Now for question two, here is what I think. I do not think that the captain was fully aware of what was ahead of him. I also do not think that the captain expected a failure on the pitot static system due to icing to occur if the flight did go into clouds.

Remember that the pitot static equipment manufacturer, France’s CAA, Airbus and AF all denied that the equipment was faulty, even though there had be several incidents of failure previously of this same equipment in this same scenario and that it had been reported in the industry press.

So that captain may have allowed himself to be informed by the “authorities” in lieu of informing himself through reading industry incident reports.

Again, there are plenty of crew members who allow themselves to be informed this same way, at airlines all over the world, pilots who do the same thing.

Those of us who doubt “authority” are few, probably less than 1/3 of all. My guess is that real doubters are even fewer than 1/3, more like 1/10!

So, here is a third question:  Why didn’t the captain jump back into his seat and take control as soon as he arrived back up front? I know that I would have. You? Sure things were confusing, alarms going off, icing, thunderstorms, panic-what better time for the captain to be in charge of the flight deck and the controls?

I hope that this mishap is eventually re-investigated by some board other than the BEA, a board that knows that they are doing a Safety Investigation and not a Legal Investigation for some future court proceedings.

In the meantime, I am blogging my thoughts to allow local safety managers around the world to think deeper about keeping their operation safe. That is my intent.

Keep in touch.