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 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

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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 for more information on AMAS and Dr. Snyder.

Visit 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 to learn more about the ACSF Air Charter Safety Symposium and to register today!

A Pilot Monitoring Culture Shift

Posted February 5, 2014 by chartersafety
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Submitted by Paul Ratté, Director of Aviation Safety Programs at USAIG and 2014 Air Charter Safety Foundation Safety Symposium Speaker. 

Recently, I was making a presentation at a conference for facility managers from a network of technical work centers.  Along with the standard folder bearing the agenda and nametag, I received an empty manila clasp envelope.  A quick glance around the room confirmed that everyone had envelopes.  I wondered about it as I headed for my seat.   

The facilitator solved the mystery soon enough.  “All right, we’re about to get started, so cell phones off and into the envelopes please.”  There was a shuffle across the room as this obviously familiar ritual was carried out.  Aiming to be polite visitors, my colleagues and I quickly conformed to local custom.  This seemed like a good practice for centering a group’s attention, and it also struck me this was a firsthand glimpse into the organization’s culture.  

The discussion for the next two hours centered on procedural compliance in the work centers. While I suspect a small number of phones never made it into the envelopes in the first place, over the course of several presentations and a short break, many more came out and stayed out as their owners not-so-discretely went back on the grid.  Yes, a Standard Operating Procedure (SOP) had been set forth.  Yes, there had been investment (the envelopes).  Yes, it was supported initially by the majority as beneficial and easy-to-follow.  No, a group in charge of establishing SOPs and enforcing procedural compliance could or would not comply with it for two hours while discussing procedural compliance.  Irony noted.  When compliance broke down, no corrections occurred on either the macro level from the facilitator, or the micro level among people seated side-by-side.  No, this SOP has not ‘stuck’ in the organization’s culture. 

I’ll leave analysis of the irresistible nature and societal impact of smartphones to the experts, but this got me thinking about how some SOPs just never get traction.  They exist in doctrine, but really just serve up a false sense of security that risks have been controlled through standardization, when they haven’t.  Many procedures developed to guide pilot monitoring suffer that fate.  Standard verbal responses are usually tightly followed in a checklist, but for standard callouts or confirming actions that are part of broad and less-rigorously scripted guidance for approach and transition sequences, we tend to readily forgive freelancing or outright lapses in ourselves and others.  Kind of like the folks and their phones at my conference. 

Pilot monitoring is a hot topic these days, especially in light of several tragic and highly publicized recent accidents in which flawed acts or omissions by the flying pilots inexplicably went uncorrected by other cockpit crewmembers.  “Monitoring” has just fairly recently been adopted as the name for what’s expected from pilots in the cockpit while they are not functioning as the flying pilot at the controls.  I recall one of my Coast Guard commanders in the early1990s wanted that position referred to as the “Safety Pilot” but it didn’t catch on.  The old reference to the Pilot-Not-Flying (PNF) was traded in for the more apt Pilot Monitoring (PM) because the former was passive, negative sounding, and non-descriptive.   The name change was a good move, but certainly is not a cure-all for deficient monitoring.   

The monitoring pilot’s task is to observe the flight in real time and maintain an independent cognitive assessment of how it’s progressing and what’s expected.  A similar assessment is separately maintained by the pilot flying.  When those agree and the actions of the flying pilot and aircraft match expectations, safety and confidence are maximized. The first to experience any doubt about the flight’s progress or actions being taken is charged with acting immediately to resolve it.  Either pilot’s view or understanding can be flawed, so the priority, at the onset of any perceived difference between expectation and performance, is to quickly identify what’s flawed, what’s right, and get both pilots realigned to the accurate view.  Done consistently, this process will keep vital elements such as flight path, altitude, speed, and configuration under redundant human control.   

As tidy as that model seems, we know there’s more to it.  Besides sitting there sensing, calculating, and comparing like a flight computer, we’re also, well, being human.  Distraction, socialization, complacency, emotions, fatigue, trust, and cultural barriers all threaten effective monitoring.  Like the weather, we can’t wish those things away.  We need the ability to consistently succeed in spite of, and while immersed in, these factors.  

We internally assign criticality rankings to things expected of us, and those change with the situation.  We’ll heed a “no trespassing, high voltage” sign most all the time, or resist the buzz of a new text message during a meeting with the boss, but reason nobody’s going to be harmed if we check email during this conference, in spite of stated group rules.  Even with an improved name, pilot monitoring is still getting factored too low on those priority scales.  Despite tacit agreement by virtually all pilots with the idea and importance of monitoring, evidence continues to show inconsistent follow-through.  The results are sometimes disastrous and, when so, seem incomprehensible because we thought we’d already managed that risk with a multi-place cockpit and a monitoring doctrine.  At the 2014 Air Charter Safety Symposium, I look forward to a discussion with flight organizations focused on elevating the quality and consistency of monitoring in their cultures.  

To return or visit ACSF’s site, go to To register for the ACSF Safety Symposium, visit

System 1 and System 2: A Perfect Team

Posted March 13, 2013 by chartersafety
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The Air Charter Safety Foundation (ACSF) just completed its annual Air Charter Safety Symposium at the National Transportation Safety Board (NTSB) Training Center in Ashburn, Virginia. The symposium provided two days of presentations and discussions on topics including developing a positive safety culture, safety leadership, and starting an aviation safety action program (ASAP).

The theme for this year’s symposium was, “Safety is an Investment: It Pays Dividends.” The event drew more than 120 representatives from the on-demand air charter and fractional aircraft ownership community, as well as various aviation industry experts. The major excitement of the symposium was the stirred up by the variety of the speakers. Instead of a typical aviation conference line up of “So-and-So Charter Company’s Director of Safety” – multiplied by 9 or 10 presentations – this event featured a broad range of professionals from within the aviation industry and outside of our industry, including an Associate Professor of Business Administration from the Darden Graduate School at the University of Virginia, Robert L. Carraway.

Carraway’s presentation was one of the most talked about of the entire event. His engaging discussion focused on two prevailing personality types and how each type approaching important decisions or risk. These personality types were presented as System 1 and System 2 people.

System 1 people believe too much analysis can cause you to get “lost in the trees” and miss the more important strategic consequences of decisions. System 1 people tend to “go with their gut” and use some emotion when they approach decisions.

System 2 people tend to believe thorough, rigorous analysis of numbers is essential for making good decisions by helping you avoid the pitfalls of faulty intuition. System 2 people live and die by rational thinking and analysis.

Attendees were asked a series of questions to determine which type of personality they tend to be and, if a five person team in their company is making an important decision, what mix of “system” types would they want on the team. The resulting discussion was both humorous and enlightening. Carraway believes the ratio of System 1 to System 2 people on any given team is almost irrelevant, so long as there is at least one individual from each personality type. Carraway said a pure System 2 approach is a waste of time, but having a System 2 individual on board is only useful if they actually have the power to influence the System 1 personalities.

The key to making a reasonable decision is in knowing how people of each personality type think and respond to various inputs. System 1 people think in terms of stories and System 2 people think in terms of numbers. System 1 people can be easily swayed by a number of factors, while System 2 people can develop tunnel vision that prevents them from making a reasonable decision.

Attendees talked about Carraway’s conference-opening presentation for the rest of the event. His discussion was not just a discussion of building safety culture or developing a safety program – it was an education in how to work with individuals who think differently from you in order to make a significant decision. Symposium attendees talked about how System 1 and System 2 thinking fits in their companies, volunteer organizations, and even personal relationships.

Did you miss the Air Charter Safety Symposium this year? If so, Carraway’s presentation was only one of several great discussions you missed! Watch the National Air Transportation Association’s Aviation Business Journal for a complete summary of the event.

By Lindsey C. McFarren, McFarren Aviation Consulting