Human Error and Training

I certainly can see why airlines with good safety records have vigorous training programs, and in many if not in most cases of mishaps, if not in all cases, human error should be found as the cause of the mishap. Let’s examine the AF Toronto mishap. Human Error: crew continued approach and landing during adverse wind field encounter. Crew did not brief a runway that had failed to have been grooved by the national airport authority contractor, presuming dry runway – like stopping performance.
I would bet dollars to donuts that the Toronto AF flight crew training program DID NOT include a segment of approach briefing covering whether or not the runway was grooved, porous friction coated or not grooved. [by the way this information is on the 10-9A page]. And yet wet runway stopping and control performance degradation is a commonly known hazard. Yet look at the investigation and you will see virtually all the blame heaped upon the flight crew, with little or no mention of this severe training deficiency. Also if the crew was trained and certified upon dispatch by AF and French CAA, why did they continue their approach to land into an adverse wind field generated by convective weather occurring in the approach corridor? Were they acting in accordance to the procedures for which they had been trained and qualified? Yet no where in the investigation do you see any questions raised about AF convective weather avoidance procedure training and why is that?

For a safety investigation to have any merit, it must identify what went wrong and what steps can be taken that will prevent the mishap from recurring. Why do so many airlines have their pilots “practice to proficiency” the windshear go around procedure, auto and manual?
Why do so many airlines require their flight crew, by procedure to brief whether or not the landing runway is grooved or not? How could any airline operating be oblivious to the notes on 10-9A about grooving? How could any airline not make this information an element of the approach runway briefing?

How could the Canadian national airport authority contractor make a decision to not groove their main instrument runway in their biggest city, or any runway in the country for that matter, and ICAO and not one other global safety authority object? How is it that ATSB could complete their investigation and not cover these subject areas? Is it possible that the humans on the ATSB made an error? Of what use is their report? What steps did they recommend to prevent the re-occurrence of this same mishap?

Is it possible, just possible, that what the ATSB really did was conduct a legal and administrative investigation where they found fault and laid blame for the damage and injury, but never really found the cause and recommended the actions to prevent a re-occurrence?

Lastly, the purpose of training is to put a crew together, working as a team, using standard operating procedures, designed to give crew members a pretty comprehensive set of well practiced actions to deal with whatever is expected to be encountered. The argument that no one can not make no mistakes is irrelevant. When you look at any and all of the major airline mishaps, the crew made massive errors, the crew did not trap the error and correct each other (two heads are better than one theory of CRM.)

I am not arguing the academic argument of purity from error. Rather I am arguing the very practical argument that a crew well trained in well written procedures will be able to handle just about anything that it encounters.

In the mishap reports that I have read, not only did one crew member make an error, but moreover other crew members did little or nothing to trap and correct the procedures in use. Take the Amsterdam Turkish B737-800 mishap where the crew allowed the aircraft to stop in the air and fall out of the sky. What kind of procedures were those? Where was the training to proficiency program for that airline?

Flaw Free or Mishap Free Operations?

We can forecast by learning from the mishaps of other organizations.

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

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

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

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

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

Allowing human errors to “fester,” to unreported and uncorrected is to set the operation up to failure. Can an operation be made error free? Of course not. But at the same time can an operation be made mishap free? Absolutely so, by finding and fixing errors as they occur.
But I believe that as humans we are constantly making errors. A good program that enables us to report and act on these errors as they first occur will enable us to always be one step ahead of the hazards and therefore operate free from mishaps.

How the NTSB, FAA and BEA Add to the Aviation Disaster Tragedy

Safety Mishap Investigations are intended to prevent the same mishap from ever happening again, from ever reoccurring. But what often really does go on during the investigations conducted by NTSB, FAA, BEA, ATSB and other national boards around the world?

Here is my opinion, here is a look into what often goes on in the name of a Safety Investigation:

Rule One: Protect Those in Power, Those with Money and Influence. Prevent those without Power, Money and Influence from gaining control of any part of the “Safety Investigation” by claiming that the “Common Good of the Traveling Public is at Risk!” Then as the board is claiming this as the reason or charter under which the board is operating and all other reasons, charters or claims to be secondary, self serving, sensationalism, self interest or distractions, proceed on protecting the powerful, moneyed and influential, the board conducts a legal based investigation in preparation for going to court. The questions of “What Happened” and “How do we keep this event from ever happening again?” are lost in the rush to “Who was at fault?” and “Who pays?”

Rule Two: Attempt to find persons and parties without Power, Money and Influence and try to legally blame them for a major element of the mishap. Avoid finding the actual cause of the mishap. This way you will not be tasked with the obvious, that is, finding actions to prevent the mishap’s recurrence the next day, next flight or next operation. This way nothing needs to be fixed and therefore no one is held accountable for not fixing the hazard sooner. Remember that a cause has to be pretty certain or it is not really a cause; rather it is just a coincidental event. But legally often just coincidental event reasoning is sufficient to assign blame.

Rule Three: Generate “Legal Uncertainty” using the term “Probable Cause” [the greatest oxymoron in this field] so that those with Power, Money and Influence have enough legal smoke screen to hide behind. Remember legally that “reasonable doubt” is enough to protect against guilt in a death case and that the generation of Uncertainty will provide that doubt. Forget all about finding causes as the board should be doing. Come up with all sorts of coincidental events about which the board is not happy and make a big deal about how fixing them is so important. Remember to avoid at all costs finding a cause, unless under Rule Two you can find someone who perished.

Rule Four: Turn all the losses of property over to the lawyers to pay compensation as assigned by courts or separate agreements.

Rule Five: Lawyers have ways of evaluating the worth of each human life lost, through a centuries old calculus of case law, gender, net worth, earning power and other accounting practices. Again, turn the loss of life litigation over to the lawyers to hash out who gets paid and how much, there by avoiding having to deal with the human emotional tragedy of loss of life, lives belonging by the way to the “Traveling Public.”

Rule Six: At some very distant point in time down the calendar, maybe at three, five, ten or twenty years, enact some attempts, often outdated by now, at fixing what was wrong in the first place, THE CAUSE(S), that everyone outside the “Parties To The Investigation” and those “Parties To the Investigation” without Power, Money or Influence thought needed to be fixed and demanded such during the investigation. The distancing in time, after the claims litigation is completed allows this process to move forward without incurring new compensation claims. It also allows the human emotional tragedy from having to ever enter into the Mishap Safety Investigation process. Turn that responsibility over to the Grief Counselors who deal with the “inevitability of tragic human loss” in everyday life and this keeps it apart from and unrelated to the investigation for convenience of the boards.

Well, that about sums it up, no?

One question though, why is there no attempt to find out what went wrong quickly so that if the condition exists in other planes, operations, airports, flight crew or other elements of the system, it could be fixed before another tragedy occurs?

Could this be why in commercial aviation we observe the essentially “same disaster” or at least, the same type of disaster reoccurring over and over again? Is the fact that the boards take years to come out with any reports not totally contrary to their basic safety charter and in fact a contributory reason that we take so long to learn the lessons of these mishaps if we ever learn them at all? Isn’t this contrary to the reasoning that every living adult tries to learn in their early years to make life successful? Why is there such a great distance in the thinking and reasoning of every living adult and the thinking and reasoning often of the major aviation safety mishap investigation boards?

Shouldn’t the purpose of a Safety Investigation be to “find out what went wrong and take action to ensure that this event never happens again?” Isn’t that what all of us do in life to keep from making the same mistake twice? Why wouldn’t that same reasoning apply when we are talking about “Flying the Traveling Public Around the World in Our Commercial Aviation system?”

Why have we all failed so miserably to make commercial aviation safer? Why have the operators and the safety people and the owners and the regulators failed to make commercial aviation a form of transportation with a mishap rate either at or very near zero? Why do some airlines, why do some airfields, why do some aircraft, why do some flight crew members operate for years mishap free, often for entire careers? Is it just chance as the lawyers would have us believe? Does that even make any logical sense? Have we ever asked an airline, a manufacturer, an airport operator or a flight crew member who has completed a career mishap free for any suggestions? If so, have we ever heeded the same?

Or are we just stuck on Rules One through Six?

Welp, look back at Rules One through Six above and you may find your answer. Are willing to defer power to the powerful and influence to the influential? Do we then will find the mishap rate continuing to hover where it is now or worse yet spike up at times, in places, with aircraft, with people? Will we all continue to spin the wheel and take our chances that the next tragedy will happen to “someone else?”

Maybe, just maybe, we could chart a different course? Could we start to do actual Mishap Safety Investigations? In many cases now what the NTSB, FAA, BEA, ATSB and other national boards do now is to protect the powerful, moneyed and influential, while at the same time fail to achieve their own chartered purpose of Safety.

When will the leadership of national mishap investigation board finally begin to do what they were established to do? Is there any leader who actually knows what they are supposed to be doing?

If so, their voices have yet to be heard.

This of course is my opinion.

Grim Safety Forecast for Air France

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

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

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

AF447 Investigation Fails to Deter Future Mishaps

It is with great sadness that I note the issuance of BEA’s recommendation for new data streaming requirements for all pax acft.
In other words, BEA is saying, “To help us reduce our costs in locating the next accident site, we would like all of you to stream your DFDR.”

Well, that pretty much sums up what BEA expects- many more mishaps. This is a terribly failed approach to a Safety Investigation of such a serious nature.

Rather, BEA should be devoting themselves to ensuring that this mishap never happens again. Plain and simple.

AF 447: Proof of Incomplete, Possibly Incorrect Investigation?

What is the purpose of a Safety Investigation of an aviation disaster?

The answer is simple and singular: the purpose of a Safety Investigation is to determine what happened and what actions can be taken to ensure that the event does not reoccur?
This is the simple and singular purpose of a Safety Investigation of an aviation disaster.

Pilot associations and other line pilot advocates world wide have been asking the question, “Has the BEA’s investigation of the AF 447 aviation disaster met the purpose of a Safety Investigation?”

Has the BEA’s investigation asked and answered the question, “What happened and what actions can be taken to ensure that the event does not reoccur?”

It is the opinion of pilot associations and line pilot advocates that the BEA’s investigation is incomplete in this regard and possibly incorrect as a result.

It appears that the question that BEA was asking and answering was, “Who was at fault and who is responsible for damages?”

Why is that important? Are the two statements of inquiry really just the different versions of the same question?

Well, actually no, not at all.

The question of “Who was at fault and who pays for the damages?” is not a safety question at all. Rather this is legal question. It addresses English Common Law negligence and compensation. The investigation does not seek to prevent further occurrences of the same event. Rather, it seeks damages for negligence.

Meanwhile the safety question, “How did this happen and what actions can be taken to ensure that the event does not reoccur?” actually does not appear to be addressed completely by BEA.

Why is this statement important? The answer is simple. Every other airline flying an aircraft manufactured by this manufacturer has been reading the BEA report over and over again. But have they found anything in the report that they can take action on to prevent this event from occurring to their operation?

If the answer is not totally and completely yes, then the investigation is incomplete and possibly incorrect.

Prevention by Investigation vs AF 447 Blame Game

If prevention of a mishap similar to the one being investigated is not the purpose of the safety mishap or incident investigation, then what is the purpose of the investigation?
If the purpose is to level blame, for one party to escape blame, to shift blame to someone else, to share blame with other parties, well then that investigation is a lawyers investigation, a damages investigation, an insurance investigation- but it is not a safety investigation. Remember that a safety investigation is purposefully tasked with determining the cause so that a prevention process can be developed to keep the event from reoccurring.
Where has the AF 447 investigation taken us in terms of prevention?
Is the investigation really living up to its purpose?

AF447 again and again?

AF447 will undoubtedly reoccur again and again because the aircraft mishap investigation board failed to discover the cause of the mishap and instead blamed the mishap on the crew. Not only is this an inaccurate and unsubstantiated conclusion, it is also a conclusion that is misinformative. No airline reading this report will be able to use the report to take steps to prevent a similar mishap from occurring again. That is a very large error on the part of the company and the country.

The sole and critically important purpose of an aircraft mishap safety investigation is to determine the cause of the mishap. Period. By accurately determining the cause of the mishap, the safety investigation informs all of us on how to prevent this mishap from occurring again.

Instead, the board doing the investigation has chosen to take their license to do a safety investigation and use the investigation as a legal tool to attempt to lay legal blame for the mishap on flight crew. This is a total aberration of the legitimacy of the entire process of safety investigations.

While companies and countries have the right to do a legal investigation to protect their legal interests, it is not their place to take the safety investigation and abscond with it for their own legal purposes. The public deserves and the industry deserves an unbiased safety mishap investigation.
What has been publish so far is not that at all.

This is a terrible miscarriage of safety and a great example of why the fox should not be guarding the hen house.

Is Your Safety Investigation Local?

The information gathered from a local investigation to determine ‘what went wrong and how do we prevent it from recurring’ needs to be local.

There is a tendency to defer investigations to higher authority, most likely because the local safety managers just do not have the equipment to analyze the DFDR and other technical records.

Yet the more that the investigation is centered locally, the more likely it is that the investigation will address the local safety issues involved with the mishap. Most often mishaps are the result of human error on the part of crew or others involved in operations or some other local element of the operation.

Yet hull and engine complete reconstruction often takes place at great expense but at no level of contribution to the prevention of future mishaps. Again the local investigators become intimidated by the metal smiths, but to what avail? How does all of that expense and effort profit us when the mistake was made elsewhere? Are some investigators really trying to conduct a belated administrative investigation of the air line operation in lieu of focusing all efforts on human error, the most common reason for aviation mishaps?

As a local safety investigator, it is most likely that the greater burden of determining what went wrong will fall eventually squarely on your shoulders.

This is why I believe strongly that all safety investigations contain a strong local component with a great focus on human error.

Go Arounds, Missed Approaches and variations?

I would like to suggest that each reader spend a few minutes thinking about how many different procedures that their airline or aviation organization has for conducting a missed approach and/or a go around.

Your first reaction might be “Just one.” But take another minute and consider the variations. Each aircraft type has a slightly different set of procedures. How about the case when an engine is inop? What if the weather is IMC and tower is using IFR procedures in the ATA?
What if the weather is VMC and tower is using VFR procedures in the ATA? How about the case of the flight executing a cleared IFR approach procedure, but when handed off to tower, the clearance reads, “Cleared for a visual approach to land?”
What if the terrain for the runway in use dictates immediate maneuvers, the weather is IMC and tower assumed that you would have broken out and is taken by surprise that you are going around and a large thunder storm is in the missed approach path?
Does your training program give line pilots training and sufficient sim practice to be superbly proficient in all types of MA/GA’s?

What if the weather is so bad that the airframe is icing up with mixed clear and rime during the last 1000 feet and the previous aircraft has not cleared the runway and now tower orders a GA? Has the crew practiced and become proficient in this scenario?

I hope that each reader considers all of the variations on MA and GA for a while and feels free to post a comment on this subject.
Thanks and more to follow on this subject.