Procedural Noncompliance

Posted November 28, 2017 by chartersafety
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By: Robert I. Baron, Ph.D
The Aviation Consulting Group

Procedures, policies, and checklists are an effective way to ensure safety-related tasks are being conducted in a standardized, pragmatic way. They are also, in most cases, a regulatory requirement. Thus, all pilots are following the procedures…right?

Wrong. Procedural noncompliance, or procedural drift, has been either a primary, or contributing, causal factor in the majority of aviation accidents. The term procedural drift refers to the continuum between textbook compliance, and how the procedure is being done in the real world. Procedural drift is not something new. We have been drifting for a very, very, long time. However, recent accidents have illuminated the ubiquity and severity of the problem, prompting the U.S. National Transportation Safety Board (NTSB) to add ‘Strengthen Procedural Compliance’ to its Most Wanted List of Aviation Safety Improvements (2015). This NTSB recommendation was largely in response to an Execuflight Hawker HS125-700A crash on approach to Akron, Ohio, in 2015. All onboard perished (2 crew and 7 passengers).

In the case of Execuflight, the links in the chain were connected in such a way that the pilots, on that day, were the enablers of an accident that was waiting to happen. The holes in the Swiss Cheese model lined up. As is often the case, there were latent threats that were inherent in the system. These latent threats included inadequate oversight by the FAA, inadequate pilot recruiting and training, procedural noncompliance, and a poor safety culture. These latent threats allowed the pilots to fly the trip together that day and commit a series of errors that culminated in a preventable crash that took the lives of all onboard.

The crash illuminated a number of issues related to procedural noncompliance. Latent threats set the accident precedents, but the pilots were the ones that enabled the accident to occur on the day of the accident. Instead of being the final safety nets to avoid such an accident, they instead were the “trigger pullers”. So why, on that day, did the pilots deviate so extensively from procedures?

There are a number of reasons why these deviations occurred, which I will delve into extensively in my upcoming presentation at the 2018 Air Charter Safety Symposium in March. But for now, suffice it to say that there were issues with the culture, oversight, hiring practices, training, and CRM.

Unfortunately, there are still many charter outfits that are operating with a similar modus operandi, where the balance of protection versus production is weighted much too heavily on the production side. This often sets the precedents for bad things to happen, such as procedural drift or noncompliance.

The good news is that all of this is avoidable, as long as your company is willing to take a proactive approach; trust me, it will be much less expensive to prevent it from happening in the first place rather than being forced to fix it reactively after the accident…but you already knew that. See you in March!

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Dr. Robert (Bob) Baron is the President and Chief Consultant of The Aviation Consulting Group (TACG). His specializations include Human Factors (HF), Safety Management Systems (SMS), Crew Resource Management (CRM), Line Operations Safety Audit (LOSA), and Fatigue Risk Management (FRM). He consults with, and provides training to, hundreds of aviation organizations on a worldwide basis.

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Regulation Rollback: Will Worker Safety Suffer?

Posted January 30, 2017 by chartersafety
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fielkow

By: Brian L. Fielkow

Throughout Donald Trump’s campaign for President, slashing regulations has been a core theme. Many of President Trump’s cabinet nominees are long standing opponents of a heavily regulated business environment. To underscore his seriousness about deregulation, Carl Icahn, a historical proponent of deregulation, will serve as Trump’s Special Advisor on regulatory reform.

As regulations are rolled back or right-sized, the concern: is safety being compromised? The answer is easy: It’s up to business leaders – both labor and management. This has always been the case regardless of the political climate.

This is especially true in the charter and business aircraft industry. From an outside viewpoint, the level of safety is measured by crashes and regulatory compliance. When we measure crashes, it’s too late. We are basing our measurements on a tragic event. When we look at compliance, at best we are looking at meeting standards that define the minimum. At worst, we are spending time jumping through hoops that really do not drive safe outcomes.

Consider the myriad of risks that lead up to a crash, including: poor planning for weather conditions, near misses at the airport or in flight, crew fatigue, and personal distractions. The list goes on. Regulations will not fix most of this. If we do not practice prevention by catching these behaviors ahead of time by utilizing voluntary safety reporting such as ASAP, then we will continue to clean up crashes.

So how do we practice prevention? I look forward to joining ACSF on March 8 to share easy, high-value tools for you to build and grow a culture of prevention. The ACSF Safety Symposium will be held at the NTSB Training Center in Ashburn, VA. Please click here for further details.

Responsibility for safety always rests with business leaders and not with regulators. You see, the government’s promulgation of regulations does not necessarily increase safety and therefore their repeal will not necessarily disrupt safety.

Safety and regulatory compliance simply are not the same. While some level of regulation clearly is essential, when politicians and regulators dictate the structure of our safety programs, there is a low probability that desirable safety outcomes will result. At their best, regulations provide only the minimum to get by. Take two hypothetical companies. Assume that both are fully compliant with all regulations. The first company has a tightly woven safety culture; values are aligned; leadership and front line employees are all engaged. The second company views safety as a cost; leadership is not engaged, unless OSHA visits or it’s time to renew insurance. The fact that both companies are compliant has nothing to do with how likely Company 1 is to yield much safer outcomes than Company 2.

When high profile safety failures occur, a knee-jerk reaction is to run to Washington D.C. for the solution. While the government can and must be a partner in promoting safety, oftentimes the promulgation of more regulations provides the appearance of action, when in reality, safety is driven and owned by the private sector.

Here’s how business leaders can drive desired safety outcomes faster than any new regulation:

Ensure your employees report a near miss without fear of retribution. This will allow you to diagnose and prevent near misses so that an actual accident does not occur in the future.

Get out on the floor. Create a system of field-behavior observations to ensure employees are following processes.

Bring your front lines inside. They have the best idea of where the risks lie and, if engaged, will be your greatest source of information. Lecture less and listen more.

Ensure an ongoing system of process audits exists. Be your own worst critic to find flaws in the system and locate areas for improvement. Don’t wait for OSHA to visit.

Promote a culture of accountability. Every employee should adopt a mindset of prevention and should be personally accountable for making this happen, both individually and peer to peer.

Implement a new employee onboarding process that instills preventative behaviors from day one. Just because a new hire knows how to execute a given job function does not mean that he or she knows how to do this in your organization and in line with your safety values.

In addition to simply repealing wasteful regulations, President Trump has the opportunity to establish a new tone between businesses and regulatory agencies. Let’s move from enforcement to collaboration. Most businesses want to operate safely and simply need the tools. What if we redirected some of our regulatory resources to helping these businesses improve, as opposed to looking for way immediately penalize them? Of course, enforcement efforts are appropriate for willful and repeat violators. For the majority of businesses who desire to operate safely, a collaborative approach will yield better results than one of assuming guilt at the outset.

If you think that changing the tone between regulators and the private sector is far-fetched, consider the fact that it is working well in so many areas. Examples include: EPA’s Smart Way initiative, OSHA’s VPP Star certification and the FAA’s self-disclosure program. Each of these highlights that public and private sectors can work collaboratively toward a shared goal.

Are you ready to uphold your end of the bargain?

Maximizing Safety Bang for the Buck – Lessons Learned from NASA

Posted November 13, 2015 by chartersafety
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By Charles Justiz, Ph.D., Managing Director, JFA Inc.drjustiz2

Years ago, I had the great honor of being assigned as the Aviation Safety Officer at the NASA Johnson Space Center. It is important to know that at that time, JSC had nine different types of aircraft, 40 total airplanes, and was flying over 15,000 hours a year. However, these were mostly research aircraft. Only one of our airplanes was flying a mission for which it was originally designed. To make matters worse, I thought I had a handle on my new job and how to tackle it.

Fortunately for me, I had an opportunity to share a full day of flying in two different airplane types with one of the best pilots we had. He wasted no time grilling me on what I was going to do to improve our risk management, and I was gamely answering him, or so I thought until my fellow pilot went quiet. I had flown with this pilot and been in enough meetings with him to know he wanted to tell me something but wanted to phrase it precisely. Finally, he began asking seemingly unrelated questions. How strong did I think we were as a group at situational awareness? Was our safety culture strong? How was our learning culture? Does everybody land a given airplane the same way? If not, why not? On and on he went without ever offering any answers.

We got out of one airplane and stepped into another without skipping a beat in our conversation. When he felt he’d heard enough of my answers in one area, he’d shift gears. Had I ever heard of Juan Manuel Fangio, J. Bruce Ismay, John Kiker, or Max Pruss? When was a mission too risky? Is safety job one? Should we carry a desalinization pack in our survival kits? Why should we have safety metrics? What kind? Why?

My fellow pilot went quiet again. Finally, I asked him what he would do if he had my job. He looked surprised and asked what good his opinion was. I was going to point out that he had a ton more experience than I did and had flown in more aircraft types than anyone I knew. For that matter, he’d been to the moon (twice) and walked on the surface (once). He cut me off with a wave of his hand before I could say any of it. He pointed out that anything he said would automatically become dogma. He said I was in great shape since I knew how to think and hadn’t yet been told what I was supposed to think.

From that point on, once a month, he would search me out, and we would talk about aviation and safety. I remember that in all our conversations, the phrase he repeated most was, “why.” Soon, others were joining the conversation that blossomed into something larger. Out of such a simple beginning, we established processes where safety initiatives such as CRM, SMS, and a dozen others were developed and adopted long before they were accepted and adopted elsewhere.

Join Dr. Charles Justiz at the ACSF 2016 Symposium where you will have an opportunity to not only ask why, but how.

Integrated Risk Management: Bridging Theory and Practice

Posted January 30, 2015 by chartersafety
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One of the most important yet misunderstood necessities in business aviation is the management of the tangible risks involved, to include the management of fatigue. Most preflight risk assessments rely on subjective ratings which are tallied and compared to an almost arbitrary score threshold. The mission’s risk is then labeled by the aggregate. The problem is that this risk evaluation is far too malleable. With the ability to change the subjective ratings of the inputs, the crew can make the risk whatever they want so that they can just get on with their day, the business of flying.

In addition to pilots letting the missionitis push the flight day forward, many flight departments don’t really know what to do about fatigue risk management. The overwhelming majority of fatigue risk management systems consist entirely of duty and flight time limitations. There are two problems with that approach. The first is that your body doesn’t care how long you are on duty. Your body cares only how long it has been awake. The second problem is one of measurement. With regard to fatigue, business aviation deals with anecdotal evidence or experience to determine how fatiguing an operation may be. Most departments just don’t know how fatiguing their operations are…or aren’t.

The problem for operators concerned enough about fatigue to measure is that most tools require a set schedule to evaluate (not happening in charter aviation), complex data entry, and a separate process for the crews to do in preflight. The psychological mix of complexity and a separate process puts that process at risk of failure or encountering heavy resistance. It doesn’t have to be that way.

What if someone developed a customizable, integrated system of risk evaluation, management and analysis that targets specific areas of interest without sacrificing the aggregate? What if subjectivity was removed from the process, giving a truer risk evaluation for each flight? What if there was a biomathematical predictive fatigue model that is effective in predicting human performance under various scenarios facing professional pilots? Would that tool be useful? What if the entire process took less than 60 seconds, archived the data, and made it available for analysis on demand?

In simplicity there is elegance. Such a tool exists and is the only integrated fatigue and risk management system. The tool was originally developed for business aviation operators and is a network of simple inputs and processes that blend together to produce meaningful proactive risk mitigation. It bridges the science and theory of fatigue prediction with the practicality of preflight risk assessment. Endorsed by USAIG, it also provides comprehensive, reactive analytics as the first simple, effective, holistic risk management system to include the analysis of human performance data.

This integrated solution was developed by an Air Charter Safety Foundation member organization. In response to reports from several research scientists who have advocated for such an integrated model for years, it’s finally here, developed for business aviation operators by business aviation operators. I look forward to discussing the history, development, advantages, scalability and current usage of this system at the Safety Symposium.

Written by: Jim Zawrotny

Visit http://www.acsf.aero/symposium for more Symposium details and a link to register.

ACSF Safety Symposium Spotlight: In the Crosshairs of Runway Incursions & Excursions

Posted January 6, 2015 by chartersafety
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When verbal communication is the primary means of controlling aircraft ground movement during taxi operations, there are concealed flaws. Similarly, there are hidden risks when an unstabilized approach is continued to touchdown or an aircraft lands downwind on a contaminated runway. These defects remain latent until the moment of truth, when human error is made.

During the first hour of my ACSF Safety Symposium session, we will examine, in some detail, the primary causes of both runway incursions and excursions using videos and animations to show how quickly ‘routine operations’ can evolve into something quite the contrary. Strategies to counter these ‘red flags’ of incursions and excursions will also be discussed.

Real life events will be the focus of the second hour as we try to find some answers to this year’s symposium theme “How do you know you’re safe”? Join us as we unveil and explore how and why decisions were or were not made during these true life happenings:

The Debrief

The Last Defense

The Worst Bad Day

Failure Is Not an Option

Written by: Al Gorthy

Visit http://www.acsf.aero/symposium for more Symposium details and a link to register.

ACSF Symposium Spotlight: FAA Medical Certification – Improving Health & Enhancing Safety

Posted December 22, 2014 by chartersafety
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Dr. Quay Snyder, President/CEO of Aviation Medicine Advisory Service (AMAS), will hold an interactive session on “Maintaining Your FAA Medical Certificate – Tips and Traps”.  AMAS’s team of board certified Aerospace Medicine physicians assists more than a hundred pilots daily and interacts on their behalf with the FAA routinely to help keep pilots flying safely. Pilot career preservation and health optimization with timely, confidential, expert advice on the full spectrum of medical and psychological conditions are AMAS keystones.

During his presentation, Dr. Snyder will provide updates on key FAA policies including obstructive sleep apnea, changes in heart disease protocols, antidepressant medication use, the FAA’s enhanced scrutiny of DUI incidents, allowed and prohibited medications and many other topics.  Efforts to revise FAA supplemental oxygen requirements and broaden eligibility for diabetic pilots are outlined.  Dr. Snyder will also discuss progress of the NBAA Safety Committee Fitness For Duty Working Group, which he chairs, and the Flight Safety Foundation’s Global Safety Initiative – OEM Project.

Participants will have ample opportunities for Q&A, both in a public forum and discretely with Dr. Snyder during the ACSF Safety Symposium.  The presentation will conclude with tips for selecting an Aviation Medical Examiner, completing the FAA’s MedXPress application and taking a medical examination while minimizing risk of adverse FAA actions.  Both pilots and flight department leadership will gain valuable insights and have take-home resources useful for their daily operations following this interactive, no-holds-barred presentation.  See www.AviationMedicine.com for more information on AMAS and Dr. Snyder.

Visit http://www.acsf.aero/symposium for more details and to register.

Why are go-around policies ineffective? The psychology of decision making during unstable approaches…

Posted February 12, 2014 by chartersafety
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The lack of go-arounds is the number one risk factor in approach and landing accidents, and the number one cause of runway excursions.

Recent analyses of the past 16 years indicate that 33% of all accidents are runway excursions, the most common type of accident. Unstable approaches occur on 3.5% to 4.0% of all approaches; meanwhile, only about 3% of these unstable approaches result in go-arounds, while 97% of aircrews in this state continue to land.

The Flight Safety Foundation (FSF), initiated a ‘Go-around Decision Making and Execution Project’ in 2011, designed to mitigate industry runway excursions due to unstable approach go-around policies.

This enhanced compliance will result from answering the research question….”why are go-around decisions that policy states should be made, actually not being made during so many unstable approaches?”

Our survey study sought to understand the etiology of compliant versus non-compliant go-around decision-making, using a unique nine dimensional method of psychological and psychosocial awareness.

Our presentation at the ACSF Safety Symposium next month; will illustrate and explain the key contributors of non-compliance by flight crews, including management’s role.

Submitted by ACSF Air Charter Safety Symposium speakers: Dr. J. Martin Smith, Dr. David W. Jamieson and Captain William F. Curtis Presage Group Inc.

There is no other decision in flying operations that could have such an impact on the industry accident rate as ‘the decision to go around’.

Visit www.acsf.aero/symposium to learn more about the ACSF Air Charter Safety Symposium and to register today!