Can Commercial Airlines Achieve ‘One Level of Safety’ By Embarking on a Program of One Level of Training?

Captain Paul Miller and Captain Dave Williams

Abstract: The paper looks at the relationship between training and safety at a major global airline and finds several important aspects. First the paper finds that the training program and the safety program are integrated. In other words, the safety program feeds directly into the training program and the training program has numerous mechanisms for remaining current with what is being developed, discovered and reported in the safety program.

Secondly, the level of training is related to the level of safety. In other words, as safety risks are evaluated by the safety program manager, the risks and their resolutions are integrated into training at that level of importance and emphasis. The response of the safety manager to systemic as well as individual and specific risks, includes responses 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.

Thirdly, the methods that the safety, training and flight standards office personnel use to meet, discuss and integrate safety, training and flight standards programs are investigated.

The paper then postulates that the achievement of safe commercial airline operations may have been achieved due to the relationship between the safety program and the training program.

The paper next looks at the relationship between training and safety at a regional airline and determines the differences in the process of integration from those observed at the major global airlines.

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 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?”

The paper postulates in conclusion that the FAA policy of One Level of Safety may become achievable when the industry embraces 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 all commercial air operators, and in specific persons involved in safety management, flight training and standards checking.  It would also be of specific interest to organizations that are tasked with regulation of the airline industry as well as manufacturers of aircraft and those offering training products and services.]

End of abstract.

Forward: The authors on occasion have used observed examples with which they are familiar, at several airlines and other flight operations. In no way is any example intended to be an endorsement of any one company’s method of operation in total nor is it intended to be a model for any other company or operation to follow, imitate or duplicate.

Rather this paper merely attempts to show how several important safety program elements can be combined so as to improve or attempt to improve overall flight safety. 

No endorsement is given, nor intended to be given by any one company or official agency. The ideas expressed here are solely the observations, analysis, conclusions, recommendations and opinions of the authors, which they formed by looking at reports and information normally obtainable through the public domain, informal research and casual conversations with flight crew members throughout the industry.  They are the opinions formed after more than forty years of flight safety and flight training work by each of the authors.

The authors believe that there are several basics, however that are critical if any safety program is going to succeed:

First, all safety is local. This means that local managers must take full responsibility for leadership in the flight safety program.  All assets, both the human resources, the equipment and operation and the financial assets are part of the business of the company. It is therefore incumbent that safety leadership be provided by the same managers who operate the company.           

Second, all safety is joint. This means that leaders in the company must exploit every avenue of coordination both within the company and from outside organizations. Examples of this include regular joint meetings of employee professional organizations and associations, regulatory and trade organizations and other authorities especially in the case of international operations. Other examples of this are programs such as ASAP[1] where the company, the FAA and the pilot association meet regularly to discuss flight events out of the ordinary. A third example would be a monthly safety meeting of the pilot trade association CAPA[2] in rotating venues.

Third, the relationship between safety and training must be alive, robust, and capable of every type of regular communications and fully integrated, so that things that are reported, as safety issues are both quickly resolved and then, just as quickly, brought into standard operations through the training and education process.

Fourth, flight operations are human endeavors and as such are subject to the full range of human factors both in strength and in weakness.  Human factors must be recognized as occurring everyday, literally 24/7, and therefore accounted for procedurally. In the same manner, the strength of the human mind, when working in combination with others is unsurpassed in solving problems. So the authors believe that training of procedures and the greater use of checklists can be an effective measure in overcoming many human factors.

Fifth, flight operations also occur in the real world, where conditions change regularly and often quickly. The communications system between and amongst all parts of flight operations therefore must be by design and practice, regular and quick.

The paper gives some insight into how one model of flight safety works. No attempt is made to claim that this is a unique model, in part or in whole, nor that this is the only possible model nor that this model is stable and unchanging. In fact because this model does rely on rapid communications, chances are that new features of the program will continue to evolve regularly.

But the basics will always remain important to success: local, joint, safety and training integration, human factors and rapid communications. If only one statement of this paper is remembered by the reader, this is the statement to remember!

1. The paper looks at the relationship between training and safety at a major global airline and finds several important aspects.

1.1. First the paper finds that the training program and the safety program are integrated.

1.1.1. In other words, the safety program feeds directly into the training program and the training program has numerous mechanisms for remaining current with what is being developed, discovered and reported in the safety program.

1.2. Secondly, the level of training is related to the level of safety.

1.2.1. In other words, as safety risks from line operations are evaluated by the safety program manager, the risks and their resolutions are integrated into training at that level of importance and emphasis. The integration can take place at anytime, meaning that continuing qualification syllabus can change during a cycle and most certainly will change year to year.

            In addition, the training program manager measures the effectiveness of the training program from two separate points of view. First, does the training program achieve success by preparing flight crews to be proficient enough to pass check rides? Second, does the training program achieve success by preparing flight crews to be proficient in line operations?

1.2.2. The response of the safety manager to systemic as well as individual and specific risks, includes responses 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.

Training can occur at many levels. Seminars with Q&A are one level. Hands on, self-paced practice with guidance from on-hand instructors is another level of training that can be used.

Here is an example of training offered on a voluntary basis to crewmembers that desire additional training and hands-on practice in aircraft automation. The safety and training managers determined that in a case-by-case basis, but not across the board, that certain crewmembers desired more training than was offered in the syllabus.

“Flight Ops and Pilot Association Volunteer Training Day Bulletin:

 AB3XX Crewmembers are invited to participate in the next Voluntary Training Day to learn about and review the FMC, ECAM, MCP and Automation of the aircraft.  The Volunteer Training Days are scheduled each month. As a reminder, the course consists of three hours of classroom, time for lunch and then three hours of free-play in the afternoon using the FMST and/or the VPT. 

This is a great opportunity to familiarize yourself with these systems before coming to training.  We encourage everyone with a training date to attend one.  It is also a great review for current Airbus crewmembers. This is a joint effort between the pilot association training committee and the company training department.

Remember, this is strictly voluntary and provides both classroom time for instruction and Q&A in the morning and then free-play in the afternoon with instructors available to help as needed.  If you have any questions about the course or you would like to attend, please contact the A3XX pilot association training committee representative.”[3]

1.2.3. Is there a direct relationship between training and safety? If in many commercial airline mishap Aircraft Accident Reports (AAR’s) the US National Transportation Safety Board (NTSB) and other investigative bodies have cited the lack of training as a factor, could that signal that there might be some definitive relationship between safety and training? Could this be our first clue that training and safety are related?

1.2.3.1. In the Little Rock AA 1525 mishap, the crew was unable to process an overload of convective weather data into a game plan for a safe arrival either at the destination or alternate. Upon landing, failure to operate the equipment was observed in the case of spoilers. Could this be a case where procedures were introduced but never adequately reinforced by training, by practice, by repetition?

1.2.3.2. In the Toronto Air France A340 mishap, the crew chose to land on a wet, tailwind runway, without grooves. Did their lack of a complete review of the runway characteristics demonstrate a lack complete training? Perhaps that subject was never covered in any Air France SOP and therefore was never covered in any AF training? Was there a procedure missing, which resulted in training that was not complete enough for line operations?

1.2.3.3. In reinvestigating the 2009 Colgan crash, the authors’ asked, “Did the Colgan training program include sophisticated icing and stall training?” If not, was the lack of sophistication in training related to the safe operation of flight? Was hands on simulator training conducted or was a media presentation employed to cover this topic?

1.2.4.Again the question is asked, “Is safety and training directly related?”

Concerning the question as to whether safety and training could be directly related, there are several problems to overcome in order to expect a common embrace of this idea in commercial aviation. Let us explain.

1.2.4.1. Training is often thought of as something that takes place with an individual. An individual is trained; training is an individual thing. We think of athletes training for example. It is not as often recognized that training is very much an organizational thing, accomplished at great expense, in the case of flight training, by the training department of an airline. While many people think that training is an individual thing, we the authors have a tenant belief that training is an organizational function. Only an organization can train, qualify and certify an individual for example.  Also training can be meant as an abstract value, a process that someone undergoes. On the other hand Training can be thought of formally, with a capital T to refer to the Training Department, the Training Committee or the Training Program.  We believe that it is important to be clear when using training to keep the context of the remarks consistent with which meaning is intended.

1.2.4.2. Another area of misunderstanding is that safety is often thought of as something that takes place with an organization, that is something systemic.  People often think that an organization is safe or not, depending on whether the organization has accidents, in the case of commercial aviation. If an airline does not have a mishap, people might think that the organization is safe. In the opposite direction, people might describe an airline that has an accident as not as safe as before.  [Ironically, safety board reports of airline mishaps often focus on the actions of individual flight crew members rather than the airline systematically per se, in the opinion of the authors, when the news is negative.  Is this an effort to distance the airline from the accident and protect the entire airline industry?]

Safety can be thought of as an abstract and subjective term when used with the small s, safety. But Safety with a capital S can mean the Safety Department, the Safety Committee and the Safety Program.

1.2.4.2.1. So sometimes the question is “ Is there a relationship between training and safety?” At other times the question is “Is there a relationship between the Training Department and the Safety Department?” We could even ask the question, “Is there a relationship between Training Department and safety?” We could even pose the question, “Is there a relationship between training and the Safety Department?”

1.2.4.2.2. For the purposes of this paper, we will focus on the first two questions, that is investigating the relationship between training and safety and between the Training Department and the Safety Department.  But we hope that we will spark the interests of the reader to explore the latter two questions on their own.

1.2.4.3. It seems that safety boards focus on the organization and the individual. In fact however, it is the safety boards that appear to most often tell us that it was the actions of individual pilots that determined the fate of the mishap aircraft and passengers. So we the authors have a basic tenant belief that safety can and does occur at the level of the individual, as well as at the organization level.

1.2.4.4. This is why we tend to think of safety and training as directly related. From the authors’ view as professional pilots, safety and training obviously have had a direct relationship at both the organizational and the individual level.  There is no way to operate high performance transport jets safely without extensive training.  We understand training to have an organizational function as well as an individual function. In the same way, professional pilots view safety is related to individuals, as much as it is related to organizations.  Again this is why we see safety and training as directly related both individually and organizationally.

1.2.5. Aviation training is based on safety. A large portion of training is related directly to non-normal, supplemental and emergency procedures, procedures that need to be known and executed correctly by flight crew to demonstrate qualification to receive certification.

1.2.5.1. Equipment malfunctions and system failures are the mainstay scenarios for simulator training.  On the basic FAA type rating ride, very often part of the ATP rating check ride, the session begins with an engine failure or fire on takeoff.  The success of the check-ride depends on the candidate’s ability to safely continue the takeoff, and return the aircraft safely to the runway, having flown a single engine instrument approach.

1.2.5.2. It appears for these ratings, that safety is the prime prerequisite for qualification and certification. If this were so, even from a loosely logical argument position, would the next logical question be, “Would more complete training, more repetitive training, more sophisticated training or more quantity of depth of training improve safety?”

Would increasing the levels of training based on the factors of completeness, repetition, sophistication or more quantity of depth make a difference in safety?

1.2.5.3. To those who argue to the negative of this question, the authors would then ask, “If not in training, where would flight crewmembers gain the competency, the practice, the sophistication, the complete exposure to handle emergencies as they arise?”

1.2.5.4. If the answer is merely the term “experience,” then is the argument for flight crewmembers to get their training-experience elsewhere?” Isn’t “experience” really just another way of expressing the idea of  “training that someone acquired somewhere else?” If asked to document experience, would not most flight crewmembers assemble the documentation of previous training, designation and certifications obtained somewhere else? Is experience just repetitive hours of routine operations or would most flight crewmembers want to make sure that their resume was rich in documentation of training, certification, designation and other provable events?

            Maybe the word experience is used to show accumulation of hours in a type of flying, such as how many hours of instrument, night, multi-engine, turbine-engine, ocean-crossing flight has one accumulated? But if the accumulation was without any formal documentation other than a logbook, if there was not much evidence of some form of supervision of that operational accumulation, how much value is placed on that form of experience?

            But if a flight crew can show strong documentation, official letters of certification and designation, things such as licenses, ratings and other official records, isn’t that the form of “experience” that commercial aviation values most highly?

            This is why the authors point once again to training, by claiming that we consider “Experience as training that some one acquired somewhere else.”  It is the training that someone received that we hold in high value because it is documented and provable. Experience on the line in routine operations as such is also of value, but the level of that measure of experience is harder to quantify and often requires a lot of assumptions as to the valuation.[4]

Is this also to argue that an airline does not have the responsibility to train? But that is troubling logic to the authors, because remember that training is procedural based.  If an airline that writes its own procedures does not undertake to train those procedures to flight crew, then who would?

If a regional airline does not do training in-house, then who is responsible for their flight crewmembers operating in accordance with their SOP? If a regional airline contracts with a training company to conduct their training, then how is the training kept current throughout the year as new safety issues are raised by flight crewmembers in daily flight operation?

In the case of contracted training, is there any relationship between the observations that many of these regional airlines do not have a functioning safety-reporting program? In the course of our investigations, the authors were told by several regional pilots that either nothing was ever done with reports of safety issues or that flight crews were discouraged from making any reports at all.

 Training for type check-rides requires a large amount of instructional time, yet is considered of such prime importance by the regulator that it forms the basis for the type and ATP ratings. Why would this training not also reflect safety concerns of airline line operations?

1.2.6. “Level of training” in commercial aviation is critical to the determination of professional competency.  Training defines competency, and level of training defines level of competency in our opinion.  Competency is the ability of a flight crewmember to do the job safely, effectively and efficiently.

1.2.6.1. In all regulatory check rides, the primary factor is “did the flight crew do everything possible to maintain safety of flight?” FAA Line Checks are graded at four levels: superior, satisfactory, debrief required and unsatisfactory, repeat required.  Failure on the part of the flight crew to maintain safety of flight usually results in an unsatisfactory grade with a repeat required.  Examples would be violating aircraft limits, violating clearance limits, failure to avoid or egress from dangerous weather and to activate appropriate procedures and equipment, such as deicing, anti icing systems and convective weather radar.

1.2.6.2. If safety of flight is maintained, crewmember competency is judged and graded on conducting operations effectively, that is in accordance with prescribed procedures.  For example did the flight crew correctly carry out a Category three instrument landing in accordance with all regulatory, company and manufacturer procedures? Did they brief the event clearly and did they rebrief any portion related to a later change given by air traffic control (ATC), such as a runway change?

1.2.6.3. If safety and effective flight is maintained, crewmembers are graded on how well they chose to employ procedures when options were provided for and no one procedure was prescribed. For example did they chose to remain on APU power and secure engines when a departure delay was encountered?

1.2.6.4. At what level of competency did the flight crew perform?

1.2.6.5. “Training” is a term which we mean to describe formal instruction of written procedures, limits and policies that have been formally promulgated by the company, regulator, manufacturer and other parties in positions of authority and responsibility. Training should be syllabus based and should be regularly reviewed to ensure that it is directly related to operations. In other words, training should support operations and operations should define training.

1.2.6.6. If for example an operation encounters icing conditions in the air and on the ground, or expects to do so, operations should have standard operating procedures (SOP), which define the required actions to be taken upon such encounters. It is our opinion that training therefore should formally instruct flight crewmembers about those procedures (SOP’s).

1.2.7. Checking should be procedurally based in our opinion. In other words, checking   should be the validation that flight crewmembers that have undergone training can perform the procedures as defined by the company, the regulator and the manufacturer.

1.2.8. Training can also be scenario based, such as in an “engine failure on takeoff at an airport with weather or terrain restrictions.” But the checking part of training should be limited to, “did the flight crew perform the written procedures correctly and safely?” Further discussions and debriefs concerning the best way to carry out procedures in a particular scenario are invaluable to training, but checking is procedural based, in our opinion, to be valid.

1.3. Thirdly, the methods that the safety and training office departments use to meet, discuss and integrate safety and training programs are investigated.

1.3.1. ASAP, FOQA, Event Reports provide streams of safety data. A company may encourage ASAP participation because it provides a massive stream of safety data. ASAP, the Aviation Safety Action Partnership accepts reports about non-intentional procedural errors occurring due to human factors. A team of company, FAA and pilot association representatives jointly review the reports to determine responses to the individual reporters and to determine if larger systemic issues could also be involved. The reports numbered well over a thousand, providing a robust and current stream of human factors safety data.

1.3.2. FOQA also provides a strong stream of data, which is used to measure how well line crewmembers overall, as a group, are complying with procedures and limits. This data informs both safety and training of areas where risk is present and how effective from a practical sense, is the training program in producing desired results.

1.3.2.1. In other words, it is one thing for one crew to pass a check ride each year. It is quite another thing to measure how well all crews comply with all procedures throughout the year. This is what FOQA does for integration of training and safety. Training has the task of producing flight crewmembers who, not only can pass regular check-rides, but also crewmembers who operate all year long according to procedures.  Has training produced operational discipline?

1.3.2.2. Training has to take a degree of responsibility and emphasize, reemphasize, train and retrain crewmembers until they, not only can demonstrate the procedures correctly, but also in fact, do the procedures correctly in line operations. This is a key step in the process of integrating safety and training.

1.3.3. Event report submissions by crewmembers are a third prime source of the safety data stream. Event reports include required reports such as for a block turn back resulting from a mechanical failure. Event reports also allow for crewmembers to make observations, suggestions and recommendations of standard procedures and safety issues. Again these number annually to be more than a thousand reports of things that crewmembers saw which needed some form of attention.  An example might be a report that ATC tends to “slam dunk” flights into a particular gateway when arriving from the east. After receiving a report, the company could place this information in a “safety alert” section of the company’s own gateway information section known as the Jeppesen 10-10 page.

1.3.4. Advanced Qualification Program (AQP). US airlines may participate in AQP in lieu of other training programs. The FAA allows for and actually requires participant airlines to continuously adjust training in response to risks rated through a training program integrated with its safety program. This would be an example of a formal integration of training and safety. AQP can occur at the initial qualification (IQ) segment of training and at the continuing qualification (CQ) segment. AQP is driven by data that the airline captures to measure training effectiveness. The measurement includes the rating of risks associated with line operations and how successfully training prepares crew members for checking events.

1.3.4.1. Arguments against AQP have been that airlines with AQP still experience accidents. The counter to that argument is that some risks may not have been accurately measured, since at least one hazard or risk went unaddressed and that resulted in an accident. Rather than shelve AQP, the argument should be to improve it by improving the risk data stream input to safety and the training improvement generated by the resolution of the risk.

1.3.4.2. AQP requires not only a robust stream of safety data into the training process; it requires a heavy commitment of time and training talent to analyze the data. This has to be done from a safety point of view, looking at the hazard and rating the risk by severity and likelihood of occurrence. It also has to be looked at from a training point of view, that is how can procedures be written, perhaps rewritten and then trained, so as to wind up with crew members ready to, not only conduct operations in accordance with standard operating procedures, but also with crew members who can work as an effective team to handle risks where not specific procedure is available.

1.3.4.3. Threat and Error Management (TEM) training and Crew Resource Management (CRM) training are good examples where AQP includes forms of team and “what if” scenario based training.

1.3.4.4. AQP seeks to create crewmembers trained to put their heads together, by being rooted in the idea that local inputs magnify training.

1.3.5. Monthly Training-Safety Committee. Company representatives meet monthly to review the rated risks. These committee members represent safety which prepares the rated risks, training which determines how well training has addressed the risks reported, flight standards which determines if current procedures are effective, are being complied with and need modification to address a risk, to be more effective in doing so, to address new equipment or FAA requirements and in some cases to address risks not previously addressed procedurally.

1.3.5.1. The committee looks at data from line operations and from training. Since the committee is part of the AQP process, it is required to provide inputs to regularly adjust AQP to keep it effective and on point. If done correctly, this process should continuously be evaluating risks, adjusting training and adjusting procedures. The goal is to have the best trained flight crew at any given time, that is crews trained to deal with current safety risks. Change is part of this process, such that safety reports are a welcome addition to the process and not an encumbrance to the process.

1.3.5.2. Part of that process involves direct input from crewmembers as discussed in ASAP, FOQA and Event Reports. Another part of that process involves direct input from the pilot association safety department. The association safety department regularly meets to determine how training and operations of the airline can be improved. The company meets monthly with the association in a safety forum to listen to and discuss issues. The process includes formal resolutions in the form of letters of agreement and memorandums of understanding between the company and the association to act on these issues and accept them as inputs to the safety integration of training.

1.3.5.2.1. Here is an example of pilot association committee members gathering to provide local inputs to the training program:

Pilot Association Safety Group Holds Meeting:

The Safety Group held its first monthly meeting of the new year on January 28th at Association headquarters. The Safety Director headed the meeting that was attended by all committees that fall under the association safety banner. Monthly planning meetings are vital because these committees are multi-functional.  This allows the association to communicate effectively as one association safety department.  Discussed are high visibility issues, i.e. accidents, incidents, FAA compliance and ASAP and FOQA trends along with risk mitigation.

The meeting was attended by the Training Committee, ASAP Committee, FOQA, ATC Liaison Chair, Advanced Technology Flight Chair, FAA Liaison, Accident Investigation Committee, Safety Communication Rep. and ARFF Liaison.

The association vice president, who has oversight of the Safety Department, attended the meeting so that he may keep the association officers abreast of all current safety, training and compliance issues. The Safety Group will continue to meet monthly throughout the year.[5]

The pilot association and company Safety Forum will meet Thursday to discuss safety issues of concern to the membership. Agenda items will include changes desired to ground operation procedure, including stairs placement, hazmat and MEL procedures. [6]

These are some samples of joint inputs into the safety program data stream.

2. The paper then postulates that the achievement of safe commercial airline operations may have been achieved due to the relationship between the safety program and the training program.

2.1. This airline has operated very close to a mishap free operation for twenty years, when taken as a function of flight crewmember caused errors.[7]

2.2. The authors believe that the integrated relationship between the safety program and the training program has helped the airline to achieve mishap free operations. This is not to say that the operations are perfect. Quite the opposite is true. As human factors go, no operation is or can be perfect. One can only hope to learn from mistakes and not make them a second time. Safety theory rewards the operation that quickly corrects its mistakes however.[8]

2.3. One of the biggest challenges a flight operation faces is how to get the word out quickly and to all crewmembers about a hazard that they might face. Along with that is the challenge to do something about it, to do it quickly and to try to get the problem fixed in the meantime. Making changes is often a daunting task and is made moreover so when multiple organizations are involved.

2.3.1. For example new construction light poles were placed too close to a ramp. It was not until an aircraft wing struck one that the rest were moved back. One organization had painted the taxi lines and another had installed the poles. Neither got together to deconflict their work until after a taxiing aircraft hit the first pole. There is not doubt that someone may have noticed the conflict, but the information never made its way up. Why?  Was the path for safety information flow not capable of handling more than internal communications?

2.4. It is believed that if a commercial airline has a safety department that is integrated with the training department, then as hazards are discovered, resolutions can be developed and immediately implemented. The authors realize that this sounds overly simplified, but that is really the procedure that seems to define what makes this operation different from before and different from other airlines.

2.5. Not only does the airline try to be able to act quickly to resolve an issue locally, it also encourages its crewmembers to do the same when operating through training.

This is a section of an article about a crew that successfully reacted to a difficult set of malfunctions and brought the aircraft safely back for a landing with not further problems[9]:

“Ph.D. Level Threat and Error Management”

This week’s ASAP eNews is a discussion of an event involving the management of several simultaneous system malfunctions. The pilot’s involved, motivated by superior leadership, were able to handle this situation in a manner befitting Doctoral candidates for Threat and Error Management, while not being distracted by any one factor.

Flight: Homebase to Alaskan gateway

Aircraft Type: Jumbo Cargo Jet

Captain’s Narrative: “During climb-out we received a SINGLE LAND Alert, with no other malfunctions indicated. Once level at FL 340, we received a HYD PRES LOW Alert followed by a HYD OFF Alert. Several subsequent malfunctions were experienced including the following: HYD SYS ISOL, YAW DAMP UPR, YAW DAMP LWR, Avionics Fan OVRD, ENG FADEC Fault, FCC Data Fault. During the process of handling these alerts, the “Tire Failure” Aural Alert sounded for each tire. I asked the First Officer to assume Pilot Flying duties and hand-fly, as we now had no autopilots, and descend the aircraft to FL 260. Meanwhile, the flight qualified jumpseater and I attempted to accomplish checklists and troubleshoot our malfunctions. The electrical synoptic appeared normal and there was no obvious resolution to the problems. The aircraft was handling normally, as well. I contacted Flight Control and Maintenance Control via SATCOM to obtain their input. Finally, I decided to declare an emergency and return to homebase. After dumping fuel, we landed uneventfully on runway 36L.”

More details about this event were revealed during a follow-up conversation with the Captain. Level at FL 340 and having experienced several simultaneous malfunctions, the Captain elected to split the flight deck into two functional units. He assigned the First Officer and one additional flight crewmember to the flying and ATC communication duties. He then designated himself and the other ACM as problem solvers.

The flight deck was busy for both units. The First Officer had to fly without both an autopilot and flight director (FD). He was later able to transfer the Captain’s flight information over to his FD display, but never recovered the autopilot. The first ACM coordinated a descent below RVSM airspace due to their automation configuration. The Captain and the second ACM prioritized which malfunction to work first. There were over 10. As a team of two, they were unable to resolve the issues plaguing their aircraft. The Captain then communicated with Flight Control and Maintenance Control to determine if there was anything else they could do to return to a normal status. After pursuing and analyzing all available information, it was determined that returning to homefield was the best course of action. An emergency was declared and approach preparations made. The Captain and First Officer resumed their normal flight deck functions.

Weather at homefield was VFR with calm winds. Approaches were landing to the South. The flight crew desired runway 18R due to its length. ATC indicated that the glide slope was inoperative for that runway. Utilizing another defense to threats, the flight crew requested runway 36L in order to have vertical guidance throughout the approach. They landed without incident shortly after this decision.

The Threat and Error Management model lists the six “Big Defenses” to threats. The flight crew on this flight methodically deployed all six, and more, in order to combat the malfunctions. They were able to keep the issues and distractions associated with these malfunctions from leading to untrapped errors. All involved on the flight deck displayed a level of professionalism that is to be commended. Their performance was an example of Ph.D. level Threat and Error Management.

Post Script: Maintenance was able to determine that a Bus Remote

Control Circuit Breaker along with a relay had failed. All were replaced and the aircraft was returned to operational status again.

2.6. Threat and Error Management has been a recent special emphasis item in AQP continuing qualification, what some may experience in non-AQP as recurrent training.  The idea is to give crewmembers procedures and training to exercise what is often been called in the past as “judgment, experience and decision-making.”

2.6.1. The achievement of safe commercial airline operations may have been achieved in part by virtue of the integrated relationship between the safety program and the training program.

3. The paper next looks at the relationship between training and safety at regional airlines and other major airlines and determines the differences in the process of integration from those observed at this major global airline.

3.1. Regional airlines and some major discount airlines seemingly have one thing in common: they like to cut costs. They cut costs by paying low salaries and low benefits, by hiring low experienced people out of the pilot pool and by working flight crews very long hours.  Another way it appears to the authors that they cut costs is by reducing training costs to the absolute minimum required. Other cost cutting is accomplished by minimizing the investment in the local airline safety program in our observations.

3.1.1. In doing research regional and discount airline input was not easily available. But comments from regional and discount airline flight crewmembers was available. We distilled this information to determine the following characteristics.

3.1.2. Regional airlines and discount major airlines will fly flight crewmembers to their maximum duty day as often as possible. While this results in 8 flight hours, it also often results in 16 hour of duty. Many regional and discount major crewmembers do not recognize any effective safety process at their airline. Instead, they have often sought safety resolution by direct contact with either their union or the FAA. Training is seen as a program to get you to fly the way that they want you to fly. However, little if any mention appears to be made of training to address risks found in line operations, such as convective weather, icing, fatigue and other human factors. With few exceptions, an adversarial relationship seems to often be in existence between management and line crew in safety issues and seldom if ever do these operations resolve safety concerns expressed by crewmembers.

3.1.3. Operations stressed by schedules that required long duty days with multiple legs and little opportunity for adequate rest, were not at all similar in character to the training syllabus. Safety and training appeared to be separated as far as possible in these types of airlines. Cost cutting in training and safety appears to have precluded resources to allow enough substance in either program to integrate and to approach any training for the risks of actual operations.

Here is an example. Regional and discount airlines often assign flight crewmembers to fly six and even eight flight segments per day. Regional pilots report to us that this tempo of operations is highly demanding.  Yet to be qualified in these airlines, a crewmember in a simulator only has to be able to demonstrate one instrument landing and not while in a fatigued state.  So is the qualification of the flight crewmember really equivalent to actual operations?   If the qualification is not equivalent to the operation, then how close is training and safety related in this segment of the commercial airline industry?

3.2. Some or all of these observations may not be true of a particular company and no claim is made here that it is. But from the comments received during our research, we wonder whether or not regional airlines and discount airlines invest the minimum in safety programs and the minimum in training programs just in an effort to cut costs? We raise the question as to whether they view safety and training as costs or investments?

3.3. This section of the paper discusses the interrelationships between formally regulated flight training programs for the airline industry and operational errors that have occurred that resulted in regional and major airline accidents. It is the authors’ opinion that many, if not most of the airline accidents are not unique and were not random irregularities.

3.3.1. Therefore we believe that these operational occurrences might have been mitigated if proper training was provided based on lessons learned from other similar accidents. Was the concept of integrating a safety and the training program ever considered?

3.3.2. If not, could it be that improved training methods might be the impetus that results in an improved level of safety for airlines in this segment?  Could one level of training for each segment of the commercial airline industry, that is for regional, discount and major global airlines translate into one level of safety for the airline industry as a whole?

3.3.3. It is the authors’ opinion that when the causal factors of aircraft accidents are viewed as they relate to curriculum and training deficiencies, that a good starting point for effective mitigation can be found, from which a higher level of training could be developed and implemented to improve the level of safety for the operation that suffered the accident. And by further thought, locally within each airline, could it perhaps be possible to arrive at a point where the development and implementation of a higher level of training can take place before any mishap has ever occurred for all airlines? If training deficiency is affecting safety, then is it not logical that to improve safety, that you would have to improve training?  Is not accident prevention tied to training? We believe so.

3.4. By analyzing recent National Transportation Safety Board (NTSB) Aircraft Accident Reports (AAR’s), a large collection of flight crewmember training deficiencies can be found.  This is part of our data stream.

3.4.1. Could local training managers then analyze their curricula and find corrective remediation that could be applied to their own training curricula without having a formal NTSB AAR of a mishap at their own airline?

3.4.2. In other words, can we learn from each other’s mistakes? If so, what can we learn?

3.5. Looking past a particular legalistic assignment of blame to flight crewmembers in an AAR and seeking out more of a procedural and/or training causal factor viewpoint, which might take some interpretation, could a local training manager compare its own local training syllabus to see if some additional training, at a higher level, would better prepare that airline’s flight crewmembers to handle the hazards identified in the AAR?

3.5.1. If so, why would this have to be required or imposed on an airline by the FAA? Why would the airline not be motivated itself to do so by the prospect of having a safer operation?

3.5.2. It is the authors’ opinion that the revision of flight crewmember training should be a responsive, dynamic and ongoing process incorporating the “best practices” available within the airline industry. Repetitive operational accidents caused by the same type operational error could perhaps serve as learning tools for everyone, thereby helping the industry as a whole to reduce and maybe one day to eliminate accidents.

3.5.3. If flight crewmembers are made aware of those operational hazards, if procedures are improved and if flight crewmembers are procedurally trained at a higher level, would that improve the level of safety accordingly? The authors believe that this would be so.

3.6. Training Process Mitigation Through Accident Analysis

3.6.1. If a fully trained and qualified flight crew can fail in the execution of a procedure, would that failure be due to pilot error or a training error? Is it possible to think of training in terms of its design and in so doing understand that there can be errors in the design of that training?

3.6.2. If it is pilot error, then was there a flaw somewhere in the system and if so, where was the flaw that allowed a crewmember to finish training, to be assigned qualification and to operate? Where in the process did the crewmember lose that qualification?

3.7. Next we will look at three mishaps wherein the authors believe that, had crewmembers been given a higher level of training, that the airline would have not experienced a mishap and the industry would have experienced a higher level of safety.

A. Let’s look at the first AAR that investigates one such accident related to training.

On August 6, 1997, Korean Air Flight 801, a Boeing 747-300 carrying 254 persons crashed into high terrain 3 miles from the runway in Guam.  The National Transportation Safety Board (NTSB) determined that the probable cause of the accident was the captain’s failure to adequately brief and execute the LOC  non-precision approach (ILS-GS out of service approach) and the first officer’s and flight engineer’s failure to monitor and cross-check the execution of the captain’s approach.  Contributing to these failures was flight crewmember fatigue and Korean Air’s inadequate flight crewmember training.[10]

            In the course of the NTSB investigation, it was determined that Korean Air flight crewmember training for the B-747 consisting of 10 simulator sessions; crewmembers were exposed to four non-precision approaches without DME and four VOR approaches with DME. All VOR approaches were conduced to runway 32 at Seoul-Kimpo Airport. All VOR approaches to runway 32 have DME collocated at the field.  Since no practice training or checking event approaches were conducted with DME displaced from the field, as was the case at the Guam Airport, where the accident occurred, the NTSB expressed concern that the lack of exposure to non-collocated DME non-precision approaches provided inadequate training for actual line operations.

In a non-collocated DME non-precision approach, pilots have to fly with decreasing mileage to the VOR and then away from the VOR to the field. Cockpit instruments show an increasing distance from navaid as the crew approaches the field, instead of decreasing.

 The segment of decreasing and minimum DME occurs at higher altitudes during the beginning portion of the approach. If a crew incorrectly considers the minimum DME to collocated with the field, then they will attempt to descend to field level, while still several miles away from the field and possibly hit high terrain away from the airport. That is what actually happened in this case; the flight crashed on a hill several miles from the runway. The NTSB concluded that the training syllabus had “insufficient training in non-precision approaches. Further, Korean Air’s reliance on the same approach for both training and checking resulted in an inadequate evaluation of the crew’s ability to execute the varied non-precision approaches that might be encountered in line operations. Therefore, the NTSB concludes that Korean Air’s training in the execution of non-precision approaches was ineffective, which contributed to the deficient performance of the flight crew.”[11]

3.7.1. But look at similar findings in other NTSB AAR. The NTSB found similar non-precision approach related factors in its investigation of the 1995 accident involving an American Airlines B-757 on a non-precision approach to Cali, Columbia, in the 1990 accident involving a MarkAir B-737 on a non-precision approach to Unalakleet, Alaska, in the 1989 accident involving a Flying Tiger B-747 that crashed while executing an NDB approach to Kuala Lumpur, Malaysia and in the 1989 incident involving a USAir B-737 executing a Localizer Backcourse approach to Kansas City, Missouri.[12]

3.7.2. Yet in each one of these accident reports, the NTSB found the crewmembers had been qualified as directed in the FAA approved training program at the airline.

3.7.3.So again the authors ask the question, “Were these cases of pilot error or training error?” Would other pilots have done the same thing given these set of circumstances?

B. The second mishap again involves flight crew procedures:

On October 31, 1994, an ATR72-212 operated by Simmons Airlines on behalf of American Eagle flight 4184 encountered freezing rain while in a holding pattern. Soon after descending from 10,000 ft to 8,000 ft, the flight crew extended the flaps to 15 degrees, received a flap warning indication and retracted the flaps. This was followed by an uncommanded roll.  The aircraft went through one complete 360-degree roll, pitching to a nose low attitude and entered a rapid decent from which the flight crew was unable to recover.  The aircraft impacted the ground at a high rate of speed near Roselawn, Indiana killing all 68 persons on board.

            During the NTSB investigation, the service history of the ATR 42 and 72 aircraft were examined for previous roll control incidents. 

“Twenty-four roll control incidents were found to have occurred and been reported between 1986 and 1996, all of which involved the ATR42.  The NTSB determined that 13 of the 24 roll control incidents were related to icing conditions.  Of the 13 icing-related incidents, 5 occurred in weather consistent with freezing drizzle/freezing rain and involved varying degrees of uncommanded aileron deflections with subsequent roll excursions.”[13]

The five rollover events cited by the NTSB between 1986-1996 included:

● AMR Eagle /Simmons Airlines at Mosinee, Wisconsin, December 22, 1988.

● Air Mauritious over the Indian Ocean, April 17, 1991.

● Ryan Air over Ireland, August 11, 1991.

● Continental Express at Newark, New Jersey, March 4, 1993.

● Continental Express at Burlington, Massachusetts, January 28, 1994.

Based on available information, the NTSB determined on June 6, 1990, that the probable cause of the December 22, 1988 roll excursion at Mosinee was “a stall induced by the accretion (buildup) of moderate to severe clear icing.” [14]

NTSB Probable Cause Statement[15]

The National Transportation Safety Board determined that the probable cause of this accident was the loss of control, attributed to a sudden and unexpected aileron hinge moment reversal that occurred after a ridge of ice accreted beyond the deice boots because:

1) ATR failed to completely disclose to operators, and incorporate in the ATR 72 airplane flight manual, flight crew operating manual and flight-crew training programs, adequate information concerning previously known effects of freezing precipitation on the stability and control characteristics, autopilot and related operational procedures when the ATR72 was operated in such conditions;

2) The French Directorate General for Civil Aviation’s (DGAC’s) inadequate oversight of the ATR 42 and 72, and its failure to take the necessary corrective action to ensure continued airworthiness in icing conditions; and

3) The DGAC’s failure to provide the FAA with timely airworthiness information developed from previous ATR incidents and accidents in icing conditions, as specified under the Bilateral Airworthiness Agreement and Annex 8 of the International Civil Aviation Organization.

Causes contributing to the accident were:

1) Federal Aviation Administration’s (FAA’s) failure to ensure that aircraft icing certification requirements, operational requirements for flight into icing conditions and FAA published aircraft icing information adequately accounted for the hazards that can result from flight in freezing rain and other icing conditions not specified in 14 Code of Federal Regulations (CFR) Part 25, Appendix C

2) FAA’s inadequate oversight of the ATR 42 and 72 to ensure continued airworthiness in icing conditions.

NTSB recommendations were as follows:

1. Require all principal operations inspectors (POI’s) of 14 CFR Part 121 and 135 operators to ensure that training programs include information about all icing conditions, including flight into freezing drizzle/freezing rain conditions (Class II, Priority Action) (A-96-61).[16]

2. Amend the Federal Aviation Regulations to require operators to provide standardized training that adequately addresses the recovery from unusual events, including extreme flight attitudes in large transport category airplanes (Class II, Priority Action) (A-96-66)[17]

C. The third training related mishap:

Now the authors want to fast forward to February 12, 2009 when a Colgan Air Inc. Bombardier Dash 8-Q400, dba Continental Connection flight 3407 crashed while on an instrument approach to Buffalo, NY Airport (BUF).  All 45 passengers and 4 crewmembers onboard were fatally injured. There was 1 ground fatality.

The captain was the pilot flying. The flight was at a cruising altitude of 16,000 ft. During the climb to 16,000 ft, all de-ice systems were selected on and remained on during the rest of the flight.  Approximately 40 minutes into the flight, the flight crew began a decent into BUF. At 9:54 p.m., the captain briefed the airspeed and flap selection for the approach.  At 10:10 p.m., the flight crew discussed the buildup of ice on the windscreen. At 10:12 p.m. the aircraft was cleared to decent to 2300 ft and reached that altitude at 10:14 p.m. The captain retarded the power levers slowing the aircraft from about 180 kts to 135 kts, called for the landing gear to be lowered and flaps selected from 5 degrees to 10 degrees. 

Shortly after, the stick shaker activated, but activated at about 25 knots above stall airspeed. The autopilot disengaged. The flight data recorder data indicated that the captain brought the power levers to approximately 75% of available power and moved the control column aft, with a degree and force amount undetermined at this time[18].

This action was accompanied by the aircraft pitching up, rolling to the left, then rolling to the right, during which time the stick pusher activated while the flaps were retracted. [19]

3.8. Look at the NTSB’s published Most Wanted List/Unacceptable Response from FAA[20] on:

● Reduce Dangers to Aircraft Flying In Icing Conditions (Design)

–Use current research on freezing rain and large water droplets to revise the way aircraft are designed and approved for flight in icing conditions. Apply revised icing requirements to currently certificated aircraft.

-Require that airplanes with pneumatic deice boots activate boots as soon as the airplane enters icing conditions.

● Reduce Accidents and Incidents Caused by Human Fatigue (Scheduling)

– Set working hour limits for flight crews, aviation mechanics and air traffic controllers based on fatigue research, circadian rhythms, sleep and rest requirements.

-Set working hour limits for flight crews, aviation mechanics and air traffic controllers based on fatigue research, circadian rhythms, and sleep and rest requirements.[21]

3.9. NTSB has connected Training and Safety in these AAR’s.

3.9.1. These three accidents, B747 Controlled Flight into Terrain (CFIT) in Guam during a non-precision approach, ATR72 in-flight loss of control and Buffalo Dash8-Q400 in-flight loss of control/CFIT all demonstrate operational errors caused by ineffective flight crewmember training, in part by poorly designed or inadequately trained procedures. There are additional contributing factors for each of these accidents.  Did fatigue play a role in all of these events? Could fatigue have reduced the ability of the crewmembers to work together, to figure out what was going wrong and to come up with an idea? Or was their training insufficient? Or was it a combination of both?

3.9.2. The ultimate fact remains that while these crewmembers reacted incorrectly to hazards with which they were faced, each crew was considered current and qualified the day that they came to work and began the flight.

3.9.3. Would these two things mean that if fully qualified and current trained crewmembers came up short in procedures to handle the hazards that they encountered in line operations, that the training that they received to be qualified was not correct by design?  Was it pilot error or was it training design error? Was their training as such a low level that it really did not prepare them for the reality of line operations?

3.9.4. If each of these crews had been given a higher level of training locally, would that training have made them proficient in handling the hazards of weather, navigation and control? Would these accidents have been prevented? The authors believe so.

3.9.5. In the authors’ opinion the airline and the industry would have achieved a higher level of safety if the crewmembers had received a higher level of training.

3.9.6. The “Art” of the Non-precision Approach (NPA)

            Observe flight crew interactions during the final segment of a non-precision approach in bad weather and you should see a finely honed team working together in the critical last few minutes of the approach to achieve a successful landing. Flight crews conduct few non-precision approaches because most airports have precision approaches available. Therefore, non-precision approaches are the exception, not the norm and practice is often at a minimum.

The number of critical flying decisions that has to make during a non-precision approach are higher than on the precision ILS precision approach.  The flying pilot must determine and control the descent rate, make step-down altitude gates, measure timing, distance and position of the runway (to the left or right, or straight ahead), level off altitude, power settings. When the runway environment is adequately sighted and called by the other pilot, the flying pilot must go from an inside instrument scan to an outside acquisition of the runway, change power settings, establish a suitable descent and then land.

This procedural workload is more demanding than an ILS. The ILS instrumentation provides a single instrument display provides much of what you need to know such as speed, altitude, lineup to the runway and height over the ground.

Non-precision approaches are done less often than ILS’s. But in bad weather doing a non-precision approach will require more procedures, more concentration on situational awareness, more decision making and thus raise the internal pulse rate of the crew. 

Would it be supportive to practice these approaches more in the simulator? Because NPA’s are not usually required, expensive simulator training time often is not spent practicing something that will be used less often. Interestingly though, these approaches are the most difficult to perform correctly and have resulted in many training failures as well as mishaps on the line. Wouldn’t more sim practice make sense?

Among airline pilots, discussing “who does what” on a NP approach provides a lesson in different practices.  Some airlines utilize a “monitored approach” where the captain would direct and monitor the FO who flew the approach.  When the captain obtains the necessary runway environment, flight control would be shifted to the captain to make the landing. For those who have been raised doing such practices, it feels normal.  For other pilots, is seems awkward and unsafe.  But increasing the level of training by including NP approaches in the syllabus would increase the level of safety of operations when these approaches are needed.

3.10 D. In this fourth case, a US regional airline was fined $2.5 million by the FAA for failing to ensure the weight of luggage was properly calculated. The agency proposed the civil penalty because of flights that operated with erroneous data between January and October of 2008.  FAA claims that the airline conducted at least 154 flights where the baggage weight logged on cargo load sheets was different than data entered into the airline’s Electronic Weight and Balance System. Erroneous data, in turn, can lead to the incorrect computation of the weight and balance of passenger-carrying aircraft, potentially affecting calculations for proper controls and reference speeds for takeoffs and landings.

“The traveling public has to be confident that airlines are following important safety rules,” Transportation Secretary Ray LaHood said. “When they are not operating to the highest levels of safety, they are subject to stiff fines.” FAA said the airline operated at least 39 more flights after being made aware of the problem.  “Our inspectors are hard at work every day across the country looking for any safety issues at airlines,’’ FAA Administrator Randy Babbitt said. “When we find an apparent violation of our safety rules we conduct an investigation, pursue civil penalties when necessary and require the airline to correct the problems.” The airline has taken corrective actions to ensure weight and balance information is confirmed pending the automation of cargo load sheets. Regardless, the violations led to a proposed fine of nearly $2.5 million. The carrier has 30 days to respond to the FAA.

3.11. But could this also be a case of “Lack of Lessons Learned?”

3.11.1. Less than five years ago, another regional airline suffered an accident caused by loading the aircraft outside weight and balance limitations. Could it be argued that regional airlines could have improved their level of safety by incorporating lessons learned from previous mishaps, but have not done so?

3.11.2. “Look at the 2003 case of Air Midwest 5481. Did the baggage loader know that the 14 bags loaded aft all weighed 97 pounds apiece, even though on FAA approved loading form used the calculation of an “average bag weight” to be 25 pounds? The loader put 25/14 on the W&Bal form. That amounted to an error of about 1000 pounds.  But no supervision or checking was done by the pilots or the company load supervisor, so the error went untrapped.  How do you teach operations with a restricted operating envelope when FAA approved calculations put W&Bal outside the CG envelope?  The company does not want to be found wrong in its procedures.  The FAA does not want to be found wrong in approving their procedures.  Neither the FAA nor the company will ask the questions and the crew will get stuck with an out of envelope experience.  How do we improve training in these areas when there is not a clear goal of the company and FAA?  Is it only after a fatal crash, a smoking hole with 21 people killed, such as in CLT case of Air Midwest 5481, that the questions get asked? Does the company and the FAA have to do a risk rating study to determine the obvious that was there already? But, nobody would go on the record to ask the question before the carnage.  How do we get “there?”[22] How can we raise the level of safety?

4. 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?”

4.1. This is not to ask 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?”

4.2. The first argument offered to oppose one level of training is to change the words around and argue against “the same training.” Our idea is not that. We do not advocate that all pilots get the same training. Why? Simply because every airline is unique, so every airline has to design training to address what it sees as the safety risks or hazards that it faces and will face.

4.3. Level Of Training in terms of practical learning:

4.3.1.Let’s again talk about the term “Level of Training,” because it is a prime focus of this paper.  The term “level of training” can mean how sophisticated was the training, how complete has been the training and how often is the training repeated, practiced and reinforced.

4.4. Level of Training in terms of Sophistication: Our argument is that every airline should have training at the same level, that is the level necessary to ensure maneuvers validation across all of the flight crewmembers and across all of the fleets of different aircraft. Let’s look at various levels of training in terms of practical learning and see if we can determine some differences:

1. Read an article

2. Read an article and do an open book test at the end.

3. Attend a lecture, attend a media-based brief

4. Receive a lecture with Q&A

5. Attend a seminar with interaction and discussion

6. Do an exercise, do a group exercise

7. Prepare for a verbal recital of a procedure

8. Do a simulator for orientation knowledge

9. Repeat a simulator for procedural training

10. Do a simulator procedural validation check

11. Practice a maneuver in a simulator 

12. Do a maneuver validation check in a simulator

13. Do a line oriented flight and check in a sim to check all maneuvers

14. Do line experience training in the aircraft

15. Do a line check in the aircraft for initial qual

16. Do a line operational safety audit regularly for all crews.

4.4.1. Each level of training results in a level of proficiency: the higher the level of training, the higher the level of proficiency. The differences in each level are that as the levels increase, training moves from simple knowledge, to procedures, to maneuvers and then to line performance in operations.

4.5. What we are advocating is that if a company procedure is required knowledge, then the level of training should occur at all levels and should only be considered complete when all sixteen steps are conducted and that knowledge is validated in routine line operations.

4.5.1. Would training at level 8, 9 or 10 yield the same proficiency as training at level 16? If the same level of safe operations is desired, would it not be logical to train all flight crewmembers to the same level of sophistication?

4.5.2. Professional athletes and professional arts performers practice repeatedly to achieve a very high level of performance. Should not professional pilots also do the same? If events in the training center are more about checking so as to complete a syllabus and less about training so as to perfect a maneuver, is training at the highest level being achieved? Is it possible that there is an over-emphasis on checking and an under-emphasis on training?

4.6. Level of Training in terms of completeness or substance:

4.6.1. Both the FAA ATP and Type Rating and Commercial Pilot Practical Test Standards provide examiners a mechanism to certify competency in CRM by observation. But is there a requirement to document a formal CRM training syllabus?  Is a three day school, with computerized personality profiling provided by the type rating? Or is the examiner likely to certify CRM just by observation over a few hour exam period?

 If by answering a few questions in flight one person could be considered qualified in CRM, why would another airline have an extensive three day CRM syllabus? Were not all of the mishap flight crewmembers in the regional mishap at Lexington qualified in CRM? Yet did their level of training allow them to merely pass a check and then do whatever they wanted to do? How well trained were they? Were they just signed off as trained, that is qualified without training? How can that be considered operating at the same level as an airline that does formal training?

4.6.2. Were there similarities in the Buffalo crash? Did crewmembers do whatever minimum training to get qualified, but then once on the line, do what ever they wanted to do in terms of CRM in the cockpit in actual operations?  Was talking the cause of the mishap? Or was talking the cause of the distraction that led to the flight crewmembers loosing focus and discipline on the task at hand? If talking were the cause, then every time a crewmember talked, a mishap would occur. So that cannot be the cause. Not flying the plane properly in the icing conditions would be the cause and the talking was a distraction from that task.

4.6.3. Would some airline training at the lowest level to achieve FAA certification bring the same level of safety to all airlines in the industry?

4.6.4. Training at the minimum level to just get by, such at level 9, results in a lower level of training than is actually achievable. Training brings discipline to any regime.[23] This is why athletes and performing artists train regularly, to bring that discipline to their game and to their art.

4.6.5. Could training at the highest level bring discipline to the flight deck?  Are the additional costs of training at the highest level a reasonable expectation if the goal is to achieve the highest level of safety? Is not training the basis for safe operations, and if not training what else could reinforce safety?

4.6.6. If the highest level of safety were the goal of the FAA, wouldn’t there be a great benefit across the commercial airline industry to move towards one level of training in order to achieve one level of safety?  Is it experience that causes a major global airline to be safe? Or is it training at the highest level possible that causes the highest level of safety?

4.7. It is one level of training to make a person familiar with what they should be doing. It is a higher level of training to make a person disciplined to do what they should be doing all the time based on internal motivation. The levels of training are not the same, and the resultant levels of safety are not the same.

4.8. It is the authors’ opinion that you can not fake discipline. Either you have it through effective training or you do not. Either you focus on the task at hand, such as flying the plane or you focus on personal discourse. Training to the level of discipline does not always appear to be a goal of many regional and discount airlines, in the opinion of the authors. Saving money by doing a lower level of training apparently results in a lower level of disciplined crewmembers. This appears to result in a lower level of safety and certainly not the same level of safety desired by the FAA across all of the commercial airline industry.

4.9. Completeness of a training syllabus.  This is an actual listing[24] of a portion of the training syllabus for crewmembers at a major airline. It is an example of some of the elements that go into training, where the level of training is achieved both by the substance of the syllabus and the level of proficiency. Consider that the list is quite long, but consider further that the proficiency of each item on the list is required to the 16th level of competency as well:

4.9.1. TCAS equipment, traffic advisory and resolution advisory maneuvers validation; Category 2/3 approach and ground ops certification; Enhanced Ground Proximity Warning Systems (EGPWS) and Controlled Flight Into Terrain (CFIT) maneuvers; Windshear encounter procedures with and without warning systems, microbursts & other convective weather, predictive windshear system procedures; Engine Failure after V1, after rotation, IMC and at night, with cross winds; specific Mountainous terrain airports engine failure procedures; Single Engine Instrument Landings and SE missed approaches; Non Precision Approaches, with all engines and with loss of an engine; Differing flap configurations procedures for Landing and Take offs; Low Speed and High Speed Rejected Takeoffs; High altitude landings and takeoffs at maximum gross weights; Visual cues only landing operations; High wind scenario training; Stall recovery and steep turns with in flight icing, in flight turbulence procedures; Cold weather ops, deicing, anti icing equipment, fluids and procedures; Runway and surface movement area signage, lighting, marking; ADS-B, ACARS, Electronic Flight Bags, Moving Airport Surface Map Displays; Maps, charting, plotting, notams, snowtams and meteorological reports and pireps; Meteorology paperwork, weather requirements for operating and flight release paper work; Redispatch, rerelease procedures; Airborne Divert procedures with or without emergencies; HAZMAT carriage and spill response, emergency Equipment and drills, in flight fires in the cabin and cargo areas; FOM, AOM limits, emergency procedures, non-normals, performance, and bulletins; Systems failures airborne down to standby systems for example in electrical, hydraulics, pressurization, equipment cooling, navigation and power plants; MEL and CDL dispatch with inoperative items procedures, with before and after block-out scenarios; Scenarios requiring decision making by crew above and beyond emergency and non normal procedures; ICAO and US ATC terminology differences and procedures; Cockpit Resource Management (CRM); Threat and Error Management (TEM); Flight physiology; Human Factors training, especially in verbal communications, radio communication, man-machine interface and fatigue; Finer points of Jeppesen SIDS, STARS, Approach Plates, 10-9, 10-9A and 10-10 pages, including RNAV waypoints, notes, altitude restrictions, routings; Continuous descent arrivals and approach procedures; Weight and balance procedures; closely spaced monitored ILS approaches with breakout maneuvers; Domestic and international RVSM procedures; special airport approach simulator training; meters vs feet altimetry procedures; transition altitude and transition level settings and differences procedures; airborne weather radar  procedures and convective weather seminar; hijacking and airborne  interception procedures and Federal Fire Arms Qualified Officers in the Cockpit procedures; procedural differences in air traffic control vs air traffic service in certain regions of Central and South America; Radar vs Non-radar environment traffic control procedures, ETOPS, RVSM, MNPS and Long range navigation procedures in both North and South Pacific and North Atlantic and emergency procedures with International Theatre Guide; CPDLC, Sat-com, HF operation procedures; ground crew marshalling signals and procedures; emergency evacuation procedures.

4.10. The high level of training that each crewmember undergoes to be qualified at this major global airline results in an operations at a high level of safety. The investment in training is very large, but the pay back is also very large by moving towards mishap free operations.

4.11.  Again the authors want to ask the reader,  “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?”

5. The paper concludes with the postulation that the FAA policy of One Level of Safety may become achievable when the industry embraces a policy of One Level of Training. 

5.1. Far be it from the authors to attempt to tell the FAA or any government regulatory agency how to do their job. The infinite details we are sure would over-whelm us in short order. We are not here to recreate the FAA.

5.2. Rather what we are offering here is a philosophy change, a change in ideas.

5.2.1. It is our belief in the idea that One Level of Safety is achievable by all segments of the commercial airline industry. 

5.2.2. We strongly believe that the integration of safety and training and that training to the highest level possible are pathways to moving the commercial airline industry towards a higher level of safety. 

5.2.3. When all segments of the commercial airline industry are able to operate at a higher level of safety, then it may be possible to for the FAA to realize its goal of achieving One Level of Safety from an operational point of view.

5.3. Is not that the goal that all customers of the commercial airline industry desire? The expectation of safe passage is a reasonable expectation and is the stated goal of every airline, the airline trade group, the government regulator and ICAO.[25]

5.3.1. Aviation safety is a key objective of ICAO and is part of the work in the following Sections and programmes. 

5.3.2. IATA allows airlines to operate safely, securely, efficiently and economically under clearly defined rules. IATA serves as an intermediary between airlines and passenger as well as cargo agents via neutrally applied agency service standards and centralized financial systems.

5.3.3. FAA: Our Mission. Our continuing mission is to provide the safest, most efficient aerospace system in the world. Our Vision. We continue to improve the safety and efficiency of flight. We are responsive to our customers and are accountable to the taxpayer and the flying public. Our Values-

* Safety is our passion. We are the world leaders in aerospace safety.

* Quality is our trademark. We serve our country, our stakeholders, our customers, and each other.

* Integrity is our character. We do the right thing, even when no one is looking.

* People are our strength. We treat people as we want to be treated.

 5.3.4. The authors think that the answer is “yes,” all customers do desire and do expect and do have a right to expect that when they do business with a commercial airline, that the level of safety is the highest achievable across every segment of the industry.

5.4. The authors believe that training is directly related to safety.

5.4.1. The authors believe that even pilots who are beginning their careers at commuter and regional airlines can operate at the same level of safety as seasoned well trained veterans if they are trained at the same level at which seasoned well trained veterans have been trained.

5.4.2. Commercial airlines that conduct training based on the hazards or risks experienced and expected in line operation, will have flight crews proficient in procedures to handle just about anything that comes along. In this way training is related to safety.

5.5. The level of training is determined by the level of operational risks encountered or expected. 

5.5.1. Training level should additionally be determined by how well the training process succeeds.

5.5.2. Training inadequate to develop proficiency would have to rise to a higher level, until proficiency is achieved. 

5.5.2.1. Mere orientation training is not considered acceptable. What is necessary is sufficient hands on and repetitive procedural practice to develop line proficiency in all procedures.

5.6. But safety is related to training as well.  Training is how you achieve safety.

5.6.1. That determination, coming both from line input and training input, could be set as a regulatory standard across the industry and could be modified by data collected local at each airline.

5.6.2. The result would be industry wide operations at the same level of safety, which has been a stated, yet unattained goal of the FAA for a number of years.

5.6.3. Training should always be reaching out to safety to find what new hazard needs to be trained for.

6. 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?

6.1. We believe that it is up to the FAA to change regulatory models. Regulators now expect each airman to be proficient.

6.1.1. The new model would require each airline to be proficient. This change would require every commercial airline to ensure that their training department was receiving inputs from their safety department that would be monitoring both line operations and training.

6.1.2. Hazards or risks will drive the data, standardized by the category of service and not by the aircraft, staffing size or other economic and non-safety or operational data. For example, an airline that operates more than 4 legs per day per flight crew or operates crew more than 8 duty hours per period would be required to do fatigue training for flight crew. Would a maneuvers validation at the level of operations be required to include 6 or 8 quick departures and arrivals in a row, while the crew was battling fatigue in order to be consistent with the level of operations?

6.2. Details of such an effort would certainly include AQP as a commercial airline standard. ASAP, FOQA, Event Reporting systems are all essential elements as well. Strong safety departments, integrated safety and training programs and inputs from employee groups within the airline would also be elements of such an effort.

6.2.1. Local and joint elements are and remain critical to every safety program.

7.  The authors hope that the paper has been of interest to all commercial air operators, and in specific to persons involved in safety management, flight training and standards checking.  It is hoped that the paper has been of specific interest to organizations that are tasked with regulation of the airline industry as well as manufacturers of aircraft and those offering training products and services.[26]

7.1. The authors hope that each commercial airline will create a training program that trains to procedures, that considers their own real world level of operations as an input data stream into the training syllabus, that they allow safety risk assessment inputs into training and that they anticipate and welcome regular changes to training. The authors further hope that each commercial airline will review safety policy to ensure that hazard reports from line crews are viewed as advantageous reports that provide an early warning of problems on operations, which if addressed and resolved will ensure mishap free operations. Part of that response should include an input into training.

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. A US Naval carrier based strike aviator, Miller served as a safety program manager at two major naval air installations and a forward deployed carrier based passenger and logistics squadron. He now serves on the European Advisory Committee, Flight Safety Foundation, a premier global safety organization. He has presented papers on safety program management, safety forecasting and planning, response based safety programs, such as ASAP and safety policy formation. He holds a degree in metallurgical engineering from Rensselaer Polytechnic Institute, a 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 All Check Airman at one regional airline and as a Line and Training captain at two others. He served as an aircraft mishap board member and as a pilots’ association safety representative. A US Navy career veteran from the maritime antisubmarine warfare patrol community, he served in numerous capacities in training, flight instruction and standards, including Director of Curriculum for the Navy’s Undergraduate Pilot Training program. He has also been a Fleet Pilot Evaluator, aircraft Model Manager and Check Airman. His goals are to train leveraging the particular characteristics of each individual so that the pilot group as a whole is not only highly standardized and but competently enhanced by the strengths each individual brings to the group. He holds a Bachelors degree in Biology from Southern Connecticut State University. Retired from flying, Captain Williams remains active in safety and training issues. His consults include disaster emergency continuity planning, preparedness and recovery programs for businesses and government in Virginia and North Carolina.

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[1] FAA Aviation Safety Action Program, updated 4 June 2009, http://www.faa.gov/about/initiatives/asap/

[2] Coalition of Airline Pilot Associations, http://www.capapilots.org/

[3] Voluntary or informal training may be implemented adhoc outside of the already FAA approved annual training plan to supplement training as is needed. In this case an additional voluntary course was set up to provide structured supplemental, albeit non-syllabus training to help flight crew bidding over to the aircraft for the first time and to bolster training for flight crew already on the aircraft.  This is an excerpt from an actual bulletin. The program was a joint effort of the pilot association and the company. This is a redacted sample article from a pilot association newspaper.

[4] US Naval Aviators make their first landing on an aircraft carrier with approximately 250 hours of “experience.” In that case the 250 hours is all highly supervised instruction experience and all meticulously documented.  That type of landing is considered a very high level of skill, yet the accumulated flight time is very low. This is an example of two ways to look at the term “experience.”

[5] This is an excerpt from an actual press release redacted to provide details without specifics of any organization and to serve only as an example.

[6] Sample announcement of an actual scheduled monthly Safety Forum meeting of company and pilot association safety officials and leaders of the company and association.

[7] One hull loss was related to an in-flight cargo fire in 2006, but the crew was able to safely land and evacuate the aircraft. The loss was due to the fire on board. Another aircraft was damaged in 1996 during an auto land, but the damage was repaired and the aircraft was returned to service. The crew was not held accountable for the damage in the investigation.

[8] “Safety theory states that mishaps are the result of hazards that went unresolved, until eventually someone got hurt and something was damaged. Theory also states that if a hazard can be resolved as soon as it is recognized, the probabilities are in favor that no one will be hurt and no damage will occur.” Paul Miller, Safety Theory, 2008 EASS.

[9] This redacted excerpt was distributed to all flight crewmembers to serve as an example of successful Threat and Error Management TEM and CRM.

[10] National Transportation Safety Board. 2000. Korean Air, B747-300, HL7468, Nimitz Hill, Guam,  Aug 6, 1997. Aircraft Accident Report NTSB/AAR -00/01. Washington, DC.

[11] Ibid 1, P.151-152

[12] Ibid 1, P. 151

[13] National Transportation Safety Board. 1996. In-Flight Encounter and Loss of Control, Simmons Airlines, dba American Eagle Flight 4184, ATR Model 72-212, N401AM, Roselawn, Indiana. October 31, 1994. NTSB/AAR-96/01.

[14] Ibid 3, p.77.

[15] Ibid 3, p. 210.

[16] Ibid 3 p.213

[17] Ibid 3 p.214

[18] Note: The Dash8/Q400 is powered by Pratt & Whitney Turboprop engines developing 4600 shp, approximately twice the power as available on the Dash8/300 of comparable weight and size. With the gear down and flaps selected to 10 degrees, this is more than adequate power in the author’s opinion to accelerate the aircraft from a near stall condition if the aircraft is not overly burdened with ice. If more than 75% power was selected, a potential overspeed condition of the gear and flaps could quickly result.  Stall shaker recovery maneuvers in the simulators are taught with the object being to lose no altitude while lowering the aircraft nose enough only to decrease the angle of attack. With excellent power response available from the Q-400, this would be the maneuver executed by the pilot flying. In the simulator, this is taught and graded as a virtually LEVEL altitude maneuver.

[19] Testimony of the Honorable Mark V. Rosenker, Acting Chairman, National Transportation Safety Board, before the Subcommittee on Aviation Operations, Safety and Security, Committee on Commerce, Science, and Transportation, United States Senate June 10, 2009.

[20] National Transportation Safety Board Most Wanted List Transportation Safety Improvements 2009, Aviation Issues,  http://www.ntsb.gov/recs/mostwanted/aviation_issues.htm

[21] Ibid 19

[22] Captain Dave Williams citing the January 8, 2003, 0847:28 eastern standard time, Air Midwest (doing business as US Airways Express) flight 5481 mishap of a Raytheon (Beechcraft) 1900D, N233YV, that crashed shortly after takeoff from runway 18R at Charlotte-Douglas International Airport, Charlotte, North Carolina. The 2 flight crewmembers and 19 passengers aboard the airplane were killed, 1 person on the ground received minor injuries, and impact forces and a postcrash fire destroyed the airplane. Flight 5481 was a regularly scheduled passenger flight to Greenville-Spartanburg International Airport, Greer, South Carolina, and was operating under the provisions of 14 Code of Federal Regulations Part 121 on an instrument flight rules flight plan. The full report is available at http://www.ntsb.gov/publictn/publictn.htm. Footnote 22 continued: The Aircraft Accident Report number is NTSB/AAR-04/01. The National Transportation Safety Board determined the probable cause(s) of this accident as follows: the airplane’s loss of pitch control during take-off. The loss of pitch control resulted from the incorrect rigging of the elevator system compounded by the airplane’s aft center of gravity, which was substantially aft of the certified aft limit.

[23]Oxford English Dictionary: Discipline: a) the practice of training people to obey rules or a code of behavior. b) the controlled behavior resulting from such training. c) an activity providing mental or physical training

[24] The list is an example of and not a specification for or endorsement of any one airline integrated safety and training program. It is a sample of what could be created when local safety and training inputs influence training.

[25] ICAO: http://www.icao.int/anb/FLS/icaosafety.html; IATA http://www.iata.org/about/mission; FAA http://www.faa.gov/about/mission/

[26] Pilot associations Monitor’s NTSB Hearing on Flight 3407; Attend FAA Hearing on Flight/Duty Time Delays.  Pilot association Government Affairs Committee members are in Washington, D.C. monitoring today’s NTSB hearing on the final release of information in last year’s crash of Continental Flight 3407 in Buffalo, NY.  Coalition of Airline Pilots Associations (CAPA) Vice President Jeff Skiles is also attending today’s NTSB hearing on behalf of CAPA.  In a press release issued today, CAPA is calling for immediate action to address serious safety concerns including pilot fatigue, pilot training, and inadequate pilot experience; all of which were cited as contributing factors to the crash that killed 50 innocent people. http://www.capapilots.org/press_room.asp

[26] Ibid 1, P. 151