Making 2016 A Successful Year for Commercial Aviation

Making 2016 a successful year for your commercial aviation organization depends on one word:  training. By emphasizing flight crew training, a commercial company equips their operating crew members with the tools to conduct flight operations smoothly and to confront any unexpected challenges successfully.  When fiscal year 2016 comes to an end, success could be measured by two matrices many organizations have in common.

First, you know that you have had a successful year if injuries to people are at a minimum. We are talking flight crews, ground crews, maintenance crews, passenger customers and all others with whom your company interacts. Deaths of course cast an irrevocable shadow over your operation. Training has been found in most if not all mishap investigations to have been lacking when injuries and death occur. Training is procedural based, so when people are involved in violation of procedures that lead to mishaps, somehow training failed to achieve a level of safe performance. Who needs a mishap investigation to tell us that? Hopefully no one. Instead of investing time in injury investigations, invest time in training, so that people are doing the job per procedures. The costs involved with injuries and death are monumental, beyond the imagination. Worse yet, after these costs have been paid, the injury and death remains, a haunting reminder of training failure.

Second to account for is damage and destruction of property, equipment, material assets, things that cost money. Nothing cuts into profits than replacing damaged and destroyed property. Worse yet is all the paperwork associated with the loss investigations. But in these investigations, it is very common to discover that people somehow did not know what they were doing when they damaged or destroyed the equipment. Why is that? Was training lacking or only minimally provided? Did the training have it's origin in the company's procedures? Want to enjoy a successful 2016? Make sure all people know what they are doing with the equipment that they use to do the job. If they are flight crew, do they know every switch, every light, every function of every system? Have they flown every procedure in the procedures manual in the simulator? Have they practiced the Go Around in the sim enough to do it well every time, smoothly every time, coordinated every time with their fellow crew member?

Training is training only when it is based on procedures. That is the definition of training: practicing the written standardized procedures associated with the company certification.  Think about that. Who knows the company's certification operating specifications? Does everyone know them?  Are all pilots educated on the subject of operations specifications? Does everyone know that the SOP is based on these Ops Specs? Does every one know that training is based on the procedures? If not, seems like it would be worthwhile to connect these dots for all employees and managers.

By training all of the people in your organization to comply with the procedures that support the ops specs, you r company could have a very successful 2016.

My Head Hurts; I Am So Tired I Can't Think: The Injury of Pilot Fatigue

Fatigue: Is It a Stress or a Strain, that is, an injury? Is fatigue an injury to the human body from which we need time to recover? Or is fatigue just being tired or over tired, a stress for which a good night’s sleep is the common remedy?
That is the question: is fatigue just a stress on the body and mind and as such something from which the body and mind can bounce back without any damage? Or is fatigue rather something more insidious and injurious than just a stress? Is it possible that fatigue is actually a strain, that is to say,  an injury, damage to the body and mind? If fatigue is an injury to the body and mind, an overstress resulting in a strain, does the body and mind need time to heal back to health from this injury? Is the time of a "good night's sleep enough time to heal from this injury?
Does repeated stress lead to more damaging strain? Can the road to recovery from the strain of fatigue to the body and mind be a lot longer than just one good night’s sleep? Is the body and mind being damaged beyond the ability to recover in a day or a weekend?
I am a professional international pilot of 40 plus years, twenty in the US Navy, much of it on carriers with extended hours, much of it at night and twenty at a global package delivery airline, much of it in international operations and much of it at night. I have a degree in liberal arts and a degree in metallurgical engineering. I have no degree in sleep-ology, so any sheep skin focused sticklers can stop reading right here.
But I am a human being who has spent many nights and days working multiple shift hours far in excess of any reasonable eight or ten hour schedule. I have been over tired, falling asleep at the switch as the saying goes from fatigue, yet been there trying to do a good job, a necessary job and trying to have a life outside of work at the same time. The one thing that I have noticed is that recovery from fatigue seems to take much more time than just one good night’s sleep. So I began to wonder why? Was I injured somehow in my mind and body to the extent that I needed to heal? But where was the injury, how can I feel it and how can I measure it? How much time did I need for full physiological recovery of my body and my mind? Was I sacrificing the health of my body and my mind for some jobs? If so, was I being separately compensated for both the work I did and the sacrificing of the health of my body and my mind?
Well again, I didn’t study physiology in college, but I did receive a reasonably good education in flight physiology during these past 40 years and I have read most of what the fatigue and sleep experts have written in industry literature.  It is all good, many studies, great work by some fine people. And I didn't study labor relations and compensation, but I did recognize that there are two issues to working at night and working extended hours repeatedly, the issue of compensation for the work and compensation for the hours past any reasonable shift.
But even then I often come away with more questions fatigue than answers.  What is the pineal gland anyway and how does it work? Does the brain need oxygen and sugar to function? Why does worry have the same affect as caffeine? Why is a hot shower so refreshing when tired? Why do kids fall asleep when tired where ever they sit down? Why do older folks struggle often with sleep?  Why do I feel so tired on weekend layovers that I just want to relax and do nothing stressful, just recover and hope for restful sleep? Why does fatigue knock your brain out like a light switch turning off, even when you are not lying down in bed? How does it know to do that? What else do we not know about fatigue?
So, in my curiosity I harkened back to my university days studying metallurgy. I remembered that we studied the physical relationship between stress and strain on a metal sample and on samples of wood, plastic, ceramics and other material. Stress is the force that is applied to the metal sample and strain is the amount of deformation that occurred to the sample piece as a result of the stress.
What we found was that for the most part, metals deform elastically under lower levels of stress and essentially return to their original shape, size and strength. This means that the stress is borne by the material and it springs back into its original being.
In physiology terms, we might say that one all nighter isn’t so bad; just get a good night’s sleep and you will bounce back, good as new and be ready to go just fine. Probably all true, especially so for lab studies.
Now back to the metal samples. As we continue to add stress to the metal samples, somewhere down the line we get strain that is no longer elastic. The sample now begins to deform. It is still strong and has some of its original strength, but it has become bent, stretched and weakened.  The stress that was put on the sample past the elastic strain point damaged the sample. It is deformed plastically, that is, it will no longer spring back into it’s original size, shape and strength.  Moreover, if the stress is continually applied, not only does the strain become a deformation in size, shape and strength, the sample will eventually break, fail and just come apart, often with a very loud bang.

Now, back to the human physiology story. Again I am not an expert, but I wondered if the human body and mind did not react in a similar manner, that is to say, that the body and mind can take some stress, some sleeplessness, and bounce back elastically with just a good night’s sleep.
But what happens to the human body and mind when the stress of sleeplessness is applied continuously, and applied over the ability to take this stress undamaged? Can the stress eventually cause a strain, that is, damage to the body and mind, damage that one good night’s sleep is insufficient time in which to recover? Can we over stress the body and mind with fatigue? Can fatigue be damage that affects the body and mind such that it is injured and needs time to recover from the injury?
I don’t know the answers to all of these questions. But I believe that these questions need to be asked. Is fatigue more of a strain at some point that just a stress? Can we do injury to our bodies and minds by stressing them with fatigue to the point that they are damaged in some manner and no longer function well? Can this damage be such that one good night’s sleep is insufficient in which to recover? Have we broken something that needs mending? Have we injured something in ourselves which needs recovery?
Is fatigue more of a strain than a stress?

My Head Hurts; I Am So Tired I Can't Think: The Injury of Pilot Fatigue

Fatigue: Is It a Stress or a Strain, that is, an injury? Is fatigue an injury to the human body from which we need time to recover? Or is fatigue just being tired or over tired, a stress for which a good night’s sleep is the common remedy?
That is the question: is fatigue just a stress on the body and mind and as such something from which the body and mind can bounce back without any damage? Or is fatigue rather something more insidious and injurious than just a stress? Is it possible that fatigue is actually a strain, that is to say,  an injury, damage to the body and mind? If fatigue is an injury to the body and mind, an overstress resulting in a strain, does the body and mind need time to heal back to health from this injury? Is the time of a "good night's sleep enough time to heal from this injury?
Does repeated stress lead to more damaging strain? Can the road to recovery from the strain of fatigue to the body and mind be a lot longer than just one good night’s sleep? Is the body and mind being damaged beyond the ability to recover in a day or a weekend?
I am a professional international pilot of 40 plus years, twenty in the US Navy, much of it on carriers with extended hours, much of it at night and twenty at a global package delivery airline, much of it in international operations and much of it at night. I have a degree in liberal arts and a degree in metallurgical engineering. I have no degree in sleep-ology, so any sheep skin focused sticklers can stop reading right here.
But I am a human being who has spent many nights and days working multiple shift hours far in excess of any reasonable eight or ten hour schedule. I have been over tired, falling asleep at the switch as the saying goes from fatigue, yet been there trying to do a good job, a necessary job and trying to have a life outside of work at the same time. The one thing that I have noticed is that recovery from fatigue seems to take much more time than just one good night’s sleep. So I began to wonder why? Was I injured somehow in my mind and body to the extent that I needed to heal? But where was the injury, how can I feel it and how can I measure it? How much time did I need for full physiological recovery of my body and my mind? Was I sacrificing the health of my body and my mind for some jobs? If so, was I being separately compensated for both the work I did and the sacrificing of the health of my body and my mind?
Well again, I didn’t study physiology in college, but I did receive a reasonably good education in flight physiology during these past 40 years and I have read most of what the fatigue and sleep experts have written in industry literature.  It is all good, many studies, great work by some fine people. And I didn't study labor relations and compensation, but I did recognize that there are two issues to working at night and working extended hours repeatedly, the issue of compensation for the work and compensation for the hours past any reasonable shift.
But even then I often come away with more questions fatigue than answers.  What is the pineal gland anyway and how does it work? Does the brain need oxygen and sugar to function? Why does worry have the same affect as caffeine? Why is a hot shower so refreshing when tired? Why do kids fall asleep when tired where ever they sit down? Why do older folks struggle often with sleep?  Why do I feel so tired on weekend layovers that I just want to relax and do nothing stressful, just recover and hope for restful sleep? Why does fatigue knock your brain out like a light switch turning off, even when you are not lying down in bed? How does it know to do that? What else do we not know about fatigue?
So, in my curiosity I harkened back to my university days studying metallurgy. I remembered that we studied the physical relationship between stress and strain on a metal sample and on samples of wood, plastic, ceramics and other material. Stress is the force that is applied to the metal sample and strain is the amount of deformation that occurred to the sample piece as a result of the stress.
What we found was that for the most part, metals deform elastically under lower levels of stress and essentially return to their original shape, size and strength. This means that the stress is borne by the material and it springs back into its original being.
In physiology terms, we might say that one all nighter isn’t so bad; just get a good night’s sleep and you will bounce back, good as new and be ready to go just fine. Probably all true, especially so for lab studies.
Now back to the metal samples. As we continue to add stress to the metal samples, somewhere down the line we get strain that is no longer elastic. The sample now begins to deform. It is still strong and has some of its original strength, but it has become bent, stretched and weakened.  The stress that was put on the sample past the elastic strain point damaged the sample. It is deformed plastically, that is, it will no longer spring back into it’s original size, shape and strength.  Moreover, if the stress is continually applied, not only does the strain become a deformation in size, shape and strength, the sample will eventually break, fail and just come apart, often with a very loud bang.

Now, back to the human physiology story. Again I am not an expert, but I wondered if the human body and mind did not react in a similar manner, that is to say, that the body and mind can take some stress, some sleeplessness, and bounce back elastically with just a good night’s sleep.
But what happens to the human body and mind when the stress of sleeplessness is applied continuously, and applied over the ability to take this stress undamaged? Can the stress eventually cause a strain, that is, damage to the body and mind, damage that one good night’s sleep is insufficient time in which to recover? Can we over stress the body and mind with fatigue? Can fatigue be damage that affects the body and mind such that it is injured and needs time to recover from the injury?
I don’t know the answers to all of these questions. But I believe that these questions need to be asked. Is fatigue more of a strain at some point that just a stress? Can we do injury to our bodies and minds by stressing them with fatigue to the point that they are damaged in some manner and no longer function well? Can this damage be such that one good night’s sleep is insufficient in which to recover? Have we broken something that needs mending? Have we injured something in ourselves which needs recovery?
Is fatigue more of a strain than a stress?

Go Around! Should We be doing More Go Around Procedures? A Report of the Recent Go Around Seminar

Commercial pilots do not often go around when an approach has gone bad. As a matter of fact about 97%  of the time, pilots have tried to salvage a good landing out of a bad approach. From that segment of attempted landings out of bad approaches comes nearly all of the fatal commercial aviation landing disasters. At least that is what seven separate groups of commercial aviation safety researchers have discovered.
Those seven separate and independent research groups presented their papers at the recent Go Around Safety Forum, June 18, 2013 held at EuroControl Headquarters in Brussels, Belgium. The Go Around Safety Forum was organized by the European Advisory Committee and the International Advisory Committee of the Flight Safety Foundation and co-sponsored by the European Regions Airline Association and EuroControl. EuroControl is the European Organization for the Safety of Air Navigation, with 39 member nations. See http://www.eurocontrol.int/ .  After working on this joint EAC-IAC project for three years, which included international meetings and a great deal of correspondence, I am pleased to say that all of the formative work, persuading our safety community that we need to look deeper into the issue of go arounds has proven to be well worth the effort manifested today in this highly unique conference. The work of EAC. has been to look ahead and find new ways to dramatically improve commercial aviation safety.



All of the papers presented are now supported by EuroControl Skybrary, an on line reference web site open to all. See http://www.skybrary.aero/index.php/Portal:Go-Around_Safety and http://www.skybrary.aero/index.php/Portal:Go-Around_Safety_Forum_Presentations.
I would like to recommend the articles concerning flight crew Go Around Procedures Training to all commercial airline safety and training managers to determine how the syllabus at your organization compares. See http://www.skybrary.aero/index.php/Go-around_Training
Author and member of European Advisory Committee (EAC) Captain Paul Miller with long time committee member Jean-Jacques Speyer VUB University and current EAC chairman and Eurocontrol Safety Manager Tzvetomir Blajev at the June 18, 2013 Go Around Safety Forum.

Independent Pilot Association representative Captain Cris Simmons (middle) with chairman of the International Advisory Committee Captain Bill Curtis (left) and Captain Martin Smith, PhD, aviation safety researcher, Presage Group (right).

Author with Zeljko Oreski, Executive VP, Int'l Federation of Air Traffic Controllers' Assns (IFATCA).


When airlines write Go Around procedures and then train their flight crew members on how to use them, somehow a disconnect may be happening.  What have here may be a failure to communicate. If only 3 out of 100 pilots is use the going around procedure when the approach goes wrong or as it is referred to in industry terms as "unstable,"  then statistics show that in that pool of the 97% of pilots who try to land, virtually all of the landing mishaps occur that involve runway over runs, excursions off of the side of the runway, short landings into terrain and other structures occur.
In safety terms, this is an area where industry wide, a great improvement in safety can be achieved if flight crew members execute a go around 100% of the time out of an unstable approach and come back around. Why there is a large disparity between what is trained and what done by line pilots is up to each airline to determine and remedy.  The Go Around Safety Forum was intended to bring the issue to the attention of the global commercial aviation community and in that regard it was a successful three year effort, capped off by the successful one day seminar. Now all of the papers, the data and discussion is available to all airlines and it now is up to the local safety managers at each airline to put this information to good use and improve safety.
Flags of the 39 European nations of Eurocontrol.

Does Fatigue Cause an Injury to the Human Body and Mind?

Fatigue: Is It a Stress or a Strain? Is fatigue an injury to the human body from which we need time to recover? Or is fatigue just being tired or over tired, for which a good night’s sleep is the common remedy?
That is the question: is fatigue just a stress on the body and mind and as such something from which the body and mind can bounce back without any damage? Or is fatigue rather something more insidious than just a stress? Is it possible that fatigue is actually a strain, that is to say,  an injury, some kind of damage to the body and mind? If fatigue is an injury to the body and mind, and overstress resulting in a strain, does the the body and mind need time to heal back to health from this injury?
Does repeated stress lead to more damaging strain? Can the road to recovery from the strain of fatigue to the body and mind be a lot longer than just one good night’s sleep?
I am a professional international pilot of 40 plus years, twenty in the US Navy, much of it on carriers with extended hours, much of it at night and twenty at a global package delivery airline, much of it in international operations and much of it at night. I have a degree in liberal arts and a degree in metallurgical engineering. I have no degree in sleep-ology, so any sheep skin focused stickler can stop reading right here.
But I am a human being who has spent many nights and days working multiple shift hours far in excess of any reasonable eight or ten hour schedule, over tired, falling asleep at the switch as the saying goes from fatigue, but trying to do a good job, a necessary job and trying to have a life outside of work at the same time. The one thing that I have noticed is that recovery from fatigue seems to take much more time than just one good night’s sleep. So I began to wonder why? Was I injured and needing to heal? But where was the injury, how can I feel it and how can I measure it? How much time did I need for full physiological recovery of my body and my mind? Was I required to sacrifice the health of my body and my mind for some jobs? If so, how am I being separately compensated for both the work I do and the sacrificing of the health of my body and my mind?
Well again, I didn’t study physiology in college, but I did receive a reasonably good education in flight physiology during these past 40 years and I have read most of what the fatigue and sleep experts have written in industry literature.  It is all good, many studies, great work by some fine people. And I didn't study labor relations and compensation, but I did recognize that there are two issues to working at night and working extended hours repeatedly, the issue of compensation for the work and compensation for the hours past any reasonable shift.
But even then I often come away with more questions fatigue than answers.  What is the pineal gland anyway and how does it work? Does the brain need oxygen and sugar to function? Why does worry have the same affect as caffeine? Why is a hot shower so refreshing when tired? Why do kids fall asleep when tired where ever they sit down? Why do older folks struggle often with sleep?  Why do I feel so tired on weekend layovers that I just want to relax and do nothing stressful, just recover and hope for restful sleep? Why does fatigue knock your brain out like a light switch turning off, even when you are not lying down in bed? How does it know to do that? What else do we not know about fatigue?
So, in my curiosity I harkened back to my university days studying metallurgy. I remembered that we studied the physical relationship between stress and strain on a metal sample and on samples of wood, plastic, ceramics and other material. Stress is the force that is applied to the metal sample and strain is the amount of deformation that occurred to the sample piece as a result of the stress.
What we found was that for the most part, metals deform elastically under lower levels of stress and essentially return to their original shape, size and strength. This means that the stress is borne by the material and it springs back into its original being.
In physiology terms, we might say that one all nighter isn’t so bad; just get a good night’s sleep and you will bounce back, good as new and be ready to go just fine. Probably all true, especially so for lab studies.
Now back to the metal samples. As we continue to add stress to the metal samples, somewhere down the line we get strain that is no longer elastic. The sample now begins to deform. It is still strong and has some of its original strength, but it has become bent, stretched and weakened.  The stress that was put on the sample past the elastic strain point damaged the sample. It is deformed plastically, that is, it will no longer spring back into it’s original size, shape and strength.  Moreover, if the stress is continually applied, not only does the strain become a deformation in size, shape and strength, the sample will eventually break, fail and just come apart, often with a very loud bang.

Now, back to the human physiology story. Again I am not an expert, but I wondered if the human body and mind did not react in a similar manner, that is to say, that the body and mind can take some stress, some sleeplessness, and bounce back elastically with just a good night’s sleep.
But what happens to the human body and mind when the stress of sleeplessness is applied continuously, and applied over the ability to take this stress undamaged? Can the stress eventually cause a strain, that is, damage to the body and mind, damage that one good night’s sleep is insufficient time in which to recover? Can we over stress the body and mind with fatigue? Can fatigue be damage that affects the body and mind such that it is injured and needs time to recover from the injury?
I don’t know the answers to all of these questions. But I believe that these questions need to be asked. Is fatigue more of a strain at some point that just a stress? Can we do injury to our bodies and minds by stressing them with fatigue to the point that they are damaged in some manner and no longer function well? Can this damage be such that one good night’s sleep is insufficient in which to recover? Have we broken something that needs mending? Have we injured something in ourselves which needs recovery?
Is fatigue more of a strain than a stress?

Asiana 214 Mishap, SFO, July 6, 2013: Stable Approaches & Go Around Procedures

Stabilized Approaches must be part of an Standard Operating Procedure (SOP) and not just a criteria, policy or even best practice.  Procedure means that it is a written set of steps, notes and it is trained by the airline, checked by the FAA and continually verified, reviewed and updated by the FAA and the airline. Part of a stabilized approach procedure must include a verbalized communication of the aircraft state and progress at several points in the approach and a verbal command to continue the approach or to Go Around as the aircraft passes these points.
One of the most important things we learned in the recent June 18, 2013 Flight Safety Foundation (FSF) Go-Around Safety Conference, sponsored jointly by EuroControl, European Regions Airline  Association (ERAA) and the European Advisory Committee and the International Advisory Committee (EAC and IAC) of the FSF, in Brussels, addressed the idea of a criteria, policy or best practice as opposed to an SOP.
[See the conference link at http://www.skybrary.aero/index.php/Portal:Go-Around_Safety]
It is one thing to have a 500ft or even a 1000 ft stabilized approach criteria.  It is quite another thing to have an SOP that all flight crew members are trained to that says if the crew does not accomplish a stabilized appraoch by 1000 ft or even 500 ft, the pilot monitoring flight crew member(s) flight crew member(s) not flying, say verbally "GO AROUND,  APPROACH UNSTABLE," and then per SOP, the pilot flying (PF) initiates the Go Around (GA)as per trained, per briefed and as published per air traffic management procedures.
Even now, even with a stabilized approach criteria or policy at 500ft or 1000 ft and a even with no fault GA policy, wherein the crews motive for going around is not called into question, air lines still need to have an SOP, a written procedure that says crew members must verbalize, "1000 feet, APPROACH STABLE, CONTINUE," or "1000 feet, APPROACH UNSTABLE, GO AROUND."
Why is this important now? Well, it has always been important.  However now we need to understand what happened to Asiana 214 and learn from it. Having seen the video of Asiana 214 approaching San Francisco International (SFO) runway 28 Left, one thing is quite noticeable. The approach appears very flat, meaning very low in altitude at a considerable distance from the stone wall at the waters edge. In lieu of the standard three degree glide slope, the aircraft appears to have essentially leveled off at 100 or 150 feet 1/4 to 1/2 mile from the seawall.
Keep in mind that the designated normal landing area on any runway is between 500 feet and 1500 feet down the runway. Add onto that, the stone wall at the waters edge appears to be approximately 1000 feet from the end of the runway.  So the aircraft landed approximately 2000 feet short from the intended point of landing, that is, the normal landing area on the runway. This means that the aircraft had descended approximatley 50ft and 100ft  below the normal 3 degree glide slope. This deviation did not occur 4 or 7 seconds from landing, but at least 1/2 mile or more from the end of the runway.
If and when the aircraft passed 1000 feet in altitude or even 500 feet during the final approach, which would have been a considerable distance from the runway, the aircraft had to have been well below glide slope. So did the airline have a procedure (SOP) that required the crew to verbalized stable or unstable and continue or go around? If so, why did the crew continue the unstable approach? Did the crew notice the unstable approach?
In addition, early reports from the NTSB identified the airspeed decreased from a landing target of 137 knots to about 109 knots. Remember that normal target speed is 130% of the stall speed at that weight or 1.3 times the stall speed.
Rounding off for argument sake, a stall speed of 100 knots, with a 30% buffer gives a landing speed of 130 knots. The stall warning stick shaker come on 5-8 knots above stall speed (or more correctly stall angle of attack).  So the crew was not flying the aircraft just a little slow, the crew was flying substantially slow, dangerously slow and into the region of rapidly rising induced drag.  The crew appeared to be unaware of the rapid decay from 137 knots to 109 knots right into the stall. I wonder if the subject of the region of reverse command in swept winged aircraft was part of the Asiana B777 training program?
Remember it is typical for crew to add 5-7 knots to give keep a margin above the minimum target speed. So that would mean most pilots would be flying at about 142 knots. The aircraft landed 30 or more knots slow. This would require a significant increase in angle of attack and nose up position, which was seen in the video at the last moments. This again is a major deviation from a stabilized approach procedure.  This deceleration should have been recognized immediately as it occurred initially below 137 knots and corrected by the crew or the crew should have commanded a go around and the GA SOP should have been initiated as soon as the airspeed fell below the target speed. The correction would have been to add substantial power and lower the nose slightly.
As it happened the aircraft was well below glide slope and very slow below landing target speed. Both of these occurred well before the aircraft arrived at the sea wall. Not having a Go Around SOP based on deviation from Stabilized Approach is a severe risk to safety. Not having a training program that covers the aerodynamic principle of the region of rising induced drag and does not address corrections is a severe risk to safety.
Concerning the Instrument Landing System (ILS) electronic glide slope for runway 28 left being inoperative, this puts a burden on the crew members in the cockpit to build an artificial glide slope using runway data. But this would have been a good training opportunity for the crew to build that approach within the aircraft flight management system. This is a standard and written procedure in the B777 flight manual. If that was not done, the runway did have precision approach path indicators known as PAPI, which when below glide slope, would have been illuminating four red lights to the left side of the landing area of the runway.
One last thing, as the initial operating experience instructor pilot sitting in the right seat should have said when things got far out of hand, "Okay, I've got it," and flown the aircraft back into safety.
Alot going on here to discuss. We all would be better off tomorrow if we all tried to understand what happened to Asiana 214 today.
Stabilized Approach Procedures, Go Around Procedures and substitutes for ILS procedures all must be part of the skills sets of B777 crew members.

Lithium-Ion Aircraft Batteries as a Passenger and Cargo Smoke/Fire Risk

In fact three aircraft have been destroyed by fires caused by lithium ion batteries, one in 2006, two in 2010. But the FAA, NTSB and other government and official agencies categorize safety as related to passenger safety or a cargo acft only hazard and of no interest to passenger airline safety, such as the current FAA and EASA Cargo Carve-out Exemption of new Flight Duty and Rest Regulations. However, by summarily ignoring the distinct ties in safety that nevertheless may validly exist between cargo airlines, passenger airlines and their respective pilots safety, FAA, EASA and others may have gravely missed the most valuable of all safety principles, that of early warning.The early warning evidence in this case was the two cargo fires caused by lithium-ion batteries.  The fire dangers of lithium ion batteries have been amply noted, the information on this hazard has been widely available and mishap reports by FAA and EASA have identified a clear and present danger since at least 2006.
Instead of keeping lithium-ion batteries away from commercial aviation however, FAA, EASA and others have made a clear choice to allow industry lobbyist lawyers to influence safety decisions when it came to lithium ion battery carriage regulation and by that same process, have kept the safety experts themselves at arms length.
No greater illustration of inverted safety logic is present in aviation government regulatory administration today than this example.
When will the FAA, EASA and other government aviation safety agencies place aviation safety experts in charge of making important public safety and industry regulatory safety decisions?
When will the direct, clear connection in commercial aviation safety between passenger and cargo airline operations be recognized by FAA, EASA and others? It is obvious that attorneys themselves appear unable to make that connection. Wouldn't the industry be better served by placing safety experts in charge of safety decisions and regulations?

US Passengers at Risk by FAA Fatigue Rule

 Passengers on domestic US airlines are now at an increased risk of being  crashed into by sleepy cargo pilots. Lawyers at the FAA used case law, negligence reasoning and other historically based legal records to reach a regulatory milestone, aligning with lawyers at   large US based package express and airborne freight haulers. The FAA pointed out that so far, when cargo pilots have had fatal crashes, they have only killed themselves. But is the regulation a millstone around the necks of cargo pilots? Industry safety experts say the risk to the passenger flying public is very real. Fatigue caused human errors can lead to massive passenger casualties. Take for instance one of the worst commercial aviation passenger disasters in history. 583 people were killed when two heavily laden B747s collided in Tenerife in 1977.   It is believed that some of the crew members who may have been on duty in excess of 15 hours, in my opinion, misunderstood ATC communications. The KLM captain was very near the end of his official duty day, but believed that if he could get airborne before the end of his duty day, that he could complete the flight to Amsterdam with his load of passengers. A good man, a man dedicated to his company, a man with a great record at the company as a captain, under the fatigue caused misconception that he had been cleared to take off, although he had not, began his takeoff roll, colliding just moments later with a Pan Am jet on a fog shrouded runway.
Now imagine hundreds of fatigued cargo pilots operating around the clock due to this FAA ruling. Imagine a sleepy cargo crew misunderstanding an ATC radio call and ramming 850,000 pounds of plane, cargo and fuel into your family in a passenger plane innocently waiting to takeoff, albeit by accident, while seated on a passenger jet, one tightly regulated by the FAA. One thing will be for sure. The lawyers from the FAA and the cargo industry will be saying, "We need to do something about this."
So, we have a chance right now to "do something about this," and we ought to do it before we witness another tragedy such as Tenerife. The FAA should let the law of the people speak for the people. After all, it is their safety that is really the first priority, is it not? Cargo carriers have prospered under FAA safety regulations, countering the claims by their lawyers that safety would cost them business losses. Check their financial records. Now check the FAA and NTSB accident records. In fact the records show that  many if not most of the cargo crashes were the result of fatigue and other human factors, and not safety regulations. The ruinous losses of these accidents is in the hundreds of millions of dollars. And these are fully  documented losses of property and lives, they are not suppositions, arguments or cases put together in a law office.
This other "study" of potential business losses due to safety regulations is purely speculative, oppositional and entirely hypothetical. There doesn't appear to be a shred of real evidence in the entire argument. So, I think that it is time that we base our decisions of safety, of life and death on reality, on data, on facts and on history and not on the unsubstantiated claims of lawyers, accountants and other business professionals.

Is Safety Necessary or Unnecessary?:Who has the better argument?

I think that we have to rethink this logic. Some who say safety is unncessary or what want proof that safety is necessary are not using good logic.

Safety recommendations do one very special thing that no other recommendation does. Safety recommendation give us SOP modifications, checklists and limitations that help us to do our operation more correctly.
Some of you may say, "Don't you mean more safely?"
I would respond by saying, "No, not more safely, but more correctly." Why? Remember that our stated goal in all operations is safety-not 90% safety but 100% safety.
So when we figure out how to do operations safer, it is really most often soon adopted as SOP. Safety finds new and better ways to operate and then training, ops and standardization offices figure out how to turn that "safety innovation" into a New SOP, limit or checklist.
Right? Isn't our SOP being revised all the time? Aren't our Jeps procedures being revised regularly? Do we not see constant improved regulations all the time?
Did all of these improvements in SOP, Jeps, limits, regs really cost us all that much money? How much money did we waste to mishaps using flawed SOP's?
So Safety is not as expensive as some would try to make us believe. In fact, more often than not, safety has reduced our costs, reduced our expenses, make our operation more correct, effective and greatly more efficient.
Remember the sight of the Delta L1011 crash in Dallas on the front page of the papers? Remember the United DC 10 crash in Sioux City all over every TV stations for weeks? Look at Tenerife, a classic air tragedy. Look at TWA 800; all over the news for months. Look at the dozens and dozens of microburst related mishaps and the hundreds of dead.
Safety helps us to do our job better. Do those that claim that "safety is guilding the lily" with unnecessary and expensive changes really have a case?
Does their argument really "hold water?" In fact hasn't safety made our operations more correct?

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

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

What are some examples of these safety improvements opposed by the FAA and A4A? Collision Avoidance Systems (TCAS) for Cargo, Flight Duty and Rest Regulations, Improved Flight Crew  Training Requirements, Cockpit Smoke Equipment, improved security, higher ATC standards for aircraft handling and routing around severe convective weather, Aircraft Rescue and Firefighting (ARFF) or Crash Fire and Rescue (CFR) at airport equipment, manning requirements and training, hazardous materials air cargo handling and carriage rules, regulations and laws.

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

Now let's talk ASAP, the Aviation Safety Action Program. A joint commercial pilot committee worked from 1993 to Sept 1995 on the Proposed Draft FAA Advisory Circular for Airline ASAP, the AC being based on the prototype successful program established by American, Allied Pilots Assn and the FAA Southwest Region several years prior. The FAA however sat on this proposed AC, until publishing their own very similar first draft AC in Oct 1998 . The Final ASAP Advisory Circular appeared I believe in 2001. Many airlines then resisted ASAP participation, until finally agreeing and adopting ASAP in the mid 2000's, fully ten years after it was initially recommended by the pilot group.

So I would challenge anything stated about safety by the FAA and A4A in terms of their advocacy and management thereof. In fact the FAA and A4A opposed ASAP and virtually all of these safety programs, that eventually became very valuable programs.

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

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

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

For safety, look to the person with a personal stake in the argument and improvement. Do not look to the supposed argument of "Cost Benefit Analysis" to find any valid and valuable safety programs.

Is SMS Working For Your Orgnaization?

Safety is like virtue, in that safety is its own reward. Here are a few additional self audit questions that supplement those provided as policy guidance by Flight Safety Foundation President Bill Voss [in the May 2012 edition of AeroSafety World http://flightsafety.org/aerosafety-world-magazine/current-issue]: 1. Is a safety program valuable and working or is it a well documented paper work of art? 2. Is the safety manager someone everyone knows, who is out and about everyday tracking down and eliminating hazards and communicating with anyone and everyone OR is the manager writing glowing self-appraisals in an office away from the operation? 3. Is the safety program in place to serve the interests of the company that is to save the company the enormous costs of the injuries and damage caused by accidents and the time wasted investigating these OR is the safety program self serving and in many ways in opposition to or in conflict with the company, standing in the way of aggressive and innovative operations? 4. Is the safety program engaged with every employee and member of the organization, every manager, supervisor and administrator OR is it a window dressing program ready to display to the next outside inspector, auditor or investigator? 5. Is the safety program constantly reinventing itself, finding what else is wrong and fixing it, keeping one step ahead of the next mishap OR is it too busy investigating last month’s accident to be involved in preventing next weeks mishap? In my opinion, if you add these five questions to the great audit base recommended by Flight Safety Foundation President Bill Voss, you might be able to use SMS as a way to make your company better and better, year after year. Remember that Safety, like virtue, is its own reward.

GoAround when Cleared for Visual Approach

This is a big ATC issue in the US, especially at airports with heavy traffic. A flight cleared for a visual approach requires so much less attention and separation than does a flight cleared for an instrument approach. International pilots flying into the US from abroad need to be aware of this differentiation in ATC procedures from what they may be accustomed to, in order that they are prepared to execute the correct GA procedure, all depending on the most recent clearance from approach control. While flying internationally, it was my experience that ATC and (or ATS) seldom if ever changed the approach clearance from an instrument to a visual, even after the crew reported "Runway IN SIGHT". Most often Approach Control just acknowledged the call and switched the flight to tower. But the flight clearance was still the same instrument clearance, and therefore MAP clearance was still valid. But most often this is not so in the US. It is a very important training goal for non-US airlines to familiarize their international crew members flying into the US to be aware of the clearance changeover by approach control, from an instrument approach to a visual approach and all that goes along with that clearance changeover, most especially being the ATC expectations for flight crew actions in the event they get a tower directed GA after being cleared for the visual approach. ATC does not expect that the crew will fly the MAP as published, but rather will stay with tower for either a visual integration into a VFR downwind pattern or a handover back to approach control for radar vectors back into the instrument patterns to return the flight back to final. If the crew just begins to fly the MAP without clearance, there may very well be separation issues, since the airspace for the MAP may not have been protected ahead of time. This again is the consequence of Approach Control changing the clearance to a visual approach.

Airlines Lobbying usurp Citizens Rights of Pilots in Latest FAA Ruling

Cargo Carriers Lawyers and the Power of Dollars Overcomes Cargo Pilots Safety Rights of One Man One Vote.

Fatigue, the greatest Human Factors problem in commercial aviation, was introduced back into the recipe of severe hazards by the work of lobbying lawyers working for the US cargo carrier industry. US Transportation officials chose to succumb to the political pressure and apparently to the financial power of lobbyists who argued that commercial cargo carriers would be subject to undue financial pressures if the cargo airlines were required to operate safely.

Instead, it appears to me that these company lawyers argued to the FAA lawyers that there is not case law that cites fatigue as causing cargo crashes that impact the public. In my opinion, no one at the FAA acts as a safety manager or safety regulator or safety administrator but rather act as lawyers and consider events related to flight operations only from the point of view of what has happened in the past. But the FEDEX B727 Tallahassee, FL fatigue related crash did not take out a neighborhood and therefore didn’t affect the public, so it appears that to an FAA lawyer only administrator, this and other similar fatigue related cargo carrier mishaps do not affect their judgment of their ability to think legally.

Did the FAA lawyers or the cargo industry lawyers look at the huge casualty costs of operating under the federal regulations as they have existed and now exist?

If, as I believe, the lawyers were trained as safety regulators, they would see the risk that fatigued cargo pilots could crash into a city such as San Diego, Philadelphia, Newark, Louisville or any number of cities overflown by cargo pilots at 5-6am at the end of a fatiguing 16 hour day of 8 or more hours of flight time.

In my opinion, the FAA is not protecting the rights of citizen pilots flying for cargo carriers. It appears to me that the FAA, the US Federal Government, is not protecting the rights of citizens living under the flight path of cargo flights arriving at 5-6am in major city hub airports. Instead, it appears to me that elected and appointed US officials are choosing to give corporation lobbying lawyers better rights than individual US citizens, so that the corporations can make more money, while the safety of the public is not protected.

The FAA Safety Policy is “One Level of Safety.” However, it appears that the FAA has dragged out some old past century bureaucrats to recreate government of the dollar, by the dollar and for the dollar, instead of “of the people, by the people and for the people,” as noted by US President Abraham Lincoln in his famous Gettysburg Address.

It is my opinion the old style bureaucrats, who have so totally screwed up the management of safety in domestic commercial aviation for so many years, should instead leave aviation safety management to people who are experienced and by this degree qualified to make decisions of regulation.

The best example is to look at the terrible mess that the FAA’s regulations have had on the US commercial airline industry. I believe that it took more than 20 years of failed regulations to institute effective wind-shear, fatigue, baggage management and TCAS standards. Now it appears that they are involved in another 20-year struggle to handle effective crew training and human factors fatigue standards.

But then we should look at all of the lives lost in the air and on the ground, the airplanes destroyed, the property destroyed year after year for the past 40 years in US domestic airline disasters? The data shows thousands of lives lost, billions of dollars destroyed, all under commercial airline operations certified and regulated by the FAA.

In my opinion it is now time that the FAA should be led by someone from the airline industry, someone who actually has some experience and therefore credentials as a successful aviation safety manager? Can the US really afford to re-create two levels of safety in commercial aviation? Was not that FAA policy already discredited years ago?

So, can anyone tell me if lawyers really study any aviation safety policy, theory or philosophy in law school? If so, I sure would like to see the law school syllabus reference, because I sure have not been able to find one.

I believe it is time for new leadership in aviation safety in America.

Practice, Procedure, Policy, Technique, Philosophy: What really is "BEST?"

This is one of the basics. Knowing these relationships helps us understand how to do alot of other things correctly. Back to basics is always valuable.
I will challenge my readers to put them in a logical order:

Practice, Procedure, Policy, Technique, Philosophy: What is the right order?

Then read my letter below.

Dear All my Friends:

With respect to the term "best practices," I would like to make a comment. What we are really fostering here is better labeled "Best Procedures." To clarify, procedures are documents, they are published, they are written down and promulgated by an authoritative source such as a company or a regulatory agency, they are dated, they are signed, they can be and almost always are formally modified, updated and changed through a formal process.

As safety advocates for Flight Safety Foundation (FSF), it is my opinion that we should be fostering Best Procedures.

The term practice most often denotes the work of an instructor in teaching students how to carry out a procedure, which the practitioner then uses as a tool for conducting the Standard Operating Procedures correctly, consistently and safely.

The follow-on term is technique. Technique is the individual styles that operators and practitioners employ to make the practice smooth, tailored to the operation and refined.

Best Procedures is what we, I believe, should be advocating. Leave the techniques and practices to the individuals who are the technicians and practitioners.

As FSF, should we not be about influencing commercial companies and regulatory agencies to set up new authoritative written and published formal methods of operating? Is not our real customer, if you will, is not our real customer each company and regulatory agency? Are not these the parties that we are really trying to address and influence?

Can we expect to address all commercial pilots (70,000 just in the US) with a suggestion on how to adjust their practices? Remember that PRACTICES ARE NOT WRITTEN DOWN. But Procedures are. So this is the difference.

And the use of the word protocol is even more problematic, because we really do not know the authority of the protocol writer?

I would encourage us and the rest of the commercial airline industry to consider using the term BEST PROCEDURES from now on and leave the practices to the practitioners.

The right order is: The ordered ideas of our own innovations become our philosophy. Our leadership transforms our philosophy into our policy. Our need for standardized action transforms policy into procedures. Operational reality creates practicality for our actions and our human factors translates practice into individual techniques.

So for my readers the correct order is: philosophy, policy, procedures, practice and technique. Any or all of them may be fostered as "best." That is the right of global free speech.

But in fostering Safety, it is my recommendation that we use the taxonomy BEST PROCEDURES. This denotes standardization, authority and actions based on research, science and accountability. The excellent safety records of organizations that adhere to this order may give you motive to agree.

Best regards, Paul Miller

"BEST PROCEDURES" vs Best Practices: which is the More Correct Taxonomy??

With respect to the term "best practices," I would like to make a comment. What we are really fostering here is better labeled "Best Procedures." To clarify, procedures are documents, they are published, they are written down and promulgated by an authoritative source such as a company or a regulatory agency, they are dated, they are signed, they can be and almost always are formally modified, updated and changed through a formal process.

As safety advocate, it is my opinion that we should be fostering Best Procedures.

The term practice most often denotes the work of an instructor in teaching students how to carry out a procedure, which the practitioner then uses as a tool for conducting the Standard Operating Procedures correctly, consistently and safely.

The follow-on term is technique. Technique is the individual styles that operators and practitioners employ to make the practice smooth, tailored to the operation and refined.

Best Procedures is what we, I believe, should be advocating. Leave the techniques and practices to the individuals who are the technicians and practitioners.

As safety advocates should we not be about influencing commercial companies and regulatory agencies to set up new authoritative written and published formal methods of operating? Is not our real customer, if you will, is not our real customer each company and regulatory agency? Are not these the parties that we are really trying to address and influence?

Can we expect to address all commercial pilots (70,000 just in the US) with a suggestion on how to adjust their practices? Remember that PRACTICES ARE NOT WRITTEN DOWN. But Procedures are. So this is the difference.

I would encourage us and the rest of the commercial airline industry to consider using the term BEST PROCEDURES from now on and leave the practices to the practitioners and the techniques to the technicians.

Taxonomy is important if we are ever going to be able to communicate.

Bad Math by ICAO?

ICAO may be fostering bad mishap math. ICAO is stating that an increase in mishaps is attributable to an increase in flight operations. If that were so mathematically, than as any airline operated more flights and or flew more hours, their mishap rate would directly increase.

But that is not the case anecdotaly, statistically, case historically or in the experience of this pilot. The author of the ICAO report is looking for the reasons for more mishaps in the wrong place. This is critically important error on the part of ICAO, especially if everyone is trying to achieve the goal of reducing aviation mishaps. ICAO math would have us reducing flight operations in order to reduce the commercial mishap rate.

But is not our goal to solve the mathematical problem of mishaps and rates by finding methods of prevention? To do so, wouldn't you have to know what are the causes of mishaps in the first place?

It is my opinion that aviation mishaps are a direct result of unresolved hazards. The rate of mishap occurrence is therefore reducible by resolving hazards to aviation as quickly as possible. As the factors affecting the rate are reduced through Safety Procedures, the numbers of mishaps will be reduced. That in my opinion is the correct Safety Math.

Accident are therefore a mathematical function of unresolved hazards and are not a mathematical function of hours flown, nor of take-offs or other related operational factors. In my opinion ICAO is using bad math to address the issue of safety hazards and accident rates.

The correct safety math is therefore a function of how quickly we can eliminate hazards. As the rate of hazard occurrence and the actual numbers of hazards are reduced, then the rate of aviation mishaps disasters will be reduced. In fact, it is actually how rapidly we eliminate hazards that also counts, since a hazard over time results in heightened mishaps. Accident Rate is a direct function of unresolved hazards and nothing else.

Even though ICAO is not providing the mathematical or safety leadership needed globally to move commercial aviation safety in the correct and desired direction, it is my hope that many other safety minded managers are, and are doing so by regularly working to quickly resolve hazards to safe flight operations.

Best regards, Paul Miller



Wednesday, December 7, 2011
ICAO Issues Global Safety Report
Aviation accidents around the world ticked higher last year, attributable to the resurgence in air traffic, according to ICAO's inaugural State of Global Aviation Safety Report issued this week.

The number of accidents attributed to scheduled commercial flights increased in 2010 to 121, compared to 113 in 2009, resulting in an accident rate of 4.0 per million departures. The accident rate in 2009 was 3.9 per million departures. While the overall number of fatalities in 2010 was below those in 2005 and 2006, there has been an increase in fatalities over the past three years, ICAO said, increasing from 670 in 2009 to 707 in 2010.

At the same time, the number of scheduled commercial flights increased by 4.5 percent globally since 2009, which represents the first significant annual growth in the sector since 2007 and coincides with an increase of 4.2 percent in the global GDP. North America, which represents a third of global air transport traffic in terms of departures, was the only region to see a small decrease (0.6 percent) in its aggregate traffic figures.

"In the context of this period of renewed growth, and in light of anticipated increases in air travel, it is imperative to maintain a very strong focus on initiatives that will further improve safety outcomes in the future. ICAO is therefore continuously developing and refining more proactive and risk-based methods to further reduce the global accident rate, enabling the safe expansion of air travel in all regions," according to the report.

"ICAO is working in partnership with the international aviation community to achieve continuous reductions in the global accident rate, with an emphasis to improve safety performance in those regions experiencing significantly higher accident rates or having specific safety challenges."

To my readers from across the globe

Welcome:
If you are a safety manager for a commercial airline, I want to extend a welcome to you. I want to offer my ideas to you to help you make your own airline safer. I know that being a Safety Manager is a very hard job. You either have the choice of doing very little and waiting until a mishap (accident) happens and then you have 2-3 years of mishap investigating to do.

OR

You can work very hard long hours to prevent mishaps from occurring in the first place.

In either case, you will work very hard. The big difference?

In the case of prevention, you will enjoy the holidays with your family, your company will be profitable and all of the employees will enjoy happy careers.

In the case of mishap investigation, you will work so very hard and in the end, realize that all of this pain, suffering, damage and all this waste could have been and should have been prevented and you will have a stack of photographs, a larger stack of papers, a huge smoking hole and a lifetime of regret.

Please follow my blog so that I can give you some ideas on how to be a successful Safety Manager.

All my best regards, Paul Miller

If you would like to send me an email to ask a question or clarify the English language part of all of this, please do.

http://paulmiller@safetyforecast.com and I will answer you individually.

Safety Tools vs Safety Managers (RevA): Which Works Best?

All safety programs are only tools. So, to do the work of Safety your company needs someone who knows how to use the tools.

The Safety Manager has to be a "skilled works-man in the trade of Safety." Programs from "on-high" in and of themselves do not Safety make.

The mistake many airlines make is to approach Safety with a not-too-smart manager, who is both excels at "bureaucratic compliance" and intimidating flightcrew, but most often someone who does not have original thoughts nor innovative thinking.

To use all of the Safety tools provided by various Safety advocate organizations a company needs a skilled Safety person, someone who knows how to use the tools to create safety. It is not enough just to dress up in the clothes and look the part, you actually have to do the work or no safety is achieved.

Six Rules for Failure?

Here are unspoken managerial safety problems. I call them:

"Miller's Six Rules to Fail-While-Complying"

1. Many companies are run by managers who do not know their own industry well. In commercial aviation many managers are not line pilots. Many managers do not come from the ranks of the company's own line holders.

2. They will act as if they are trying to comply with any program placed on them by their superiors. Their work is to comply with a regulator or industry inspector, and not necessarily make their own company operation safer.

3. But they will not embrace the spirit of these regulatory programs.

4. They will not adapt these programs to be effective for their own local operation

5. They will not innovate new programs that will work for them.

6. They will suppress any person in their organization that attempts, suggests or recommends safety innovation that falls outside of the letter of the regulation or law governing their operations.

So ICAO, FAA and other government regulators can recommend or require all types of safety programs, but were not many of these programs recommended by safety organizations and safety pioneers more than 20 years ago and longer in the case of many safety programs? So, how effective are regulators themselves at being the global advocate for commercial aviation safety?
So in my opinion, if the local organization does not do everything to help themselves, are they not more or less likely to fail?

As I read the papers, watch the news, I regularly observe regulators, major airlines and aircraft manufacturers adhering to some or all of the six rules for failure?

Examples? Crew fatigue.

Safety Manager Tool for Accident Prevention

To understand how to prevent a mishap, it is critical to understand the terms Risk and Hazard.

A hazard is a something that causes danger such as an incomplete or outdated procedure, an object such as a equipment, a malfunction or a human factor. The hazard is real, it is perceivable and most of all discoverable BEFORE any mishap, accident or incident occurs.

This is a CRITICAL part of safety theory. A Hazard is a real thing and certain people with a good safety eye can see it ahead of any accident. Some do not, but many do and can report that hazard to the safety manager, who if he or she is smart enough, can take steps to eliminate that hazard.

Why is it important to eliminate hazards?????

Safety theory says that mishaps, accident and incidents are the result of unresolved hazards. That is the sole purpose of safety investigations: identify the hazard and eliminate them.

But if you seek mishap free operations, then you have to go seek out hazards and eliminate them ahead of time. If you do that, you will enjoy mishap free operations.

A risk is defined as a product of two factors. First factor is the likelihood of the event occurring on a sliding scale from zero to 100. Think of this as a per cent of probability which could be measured from a low of very unlikely, at or near zero per cent, then all the way up to very likely, that is at or near 100%.
The second factor is the severity of the event if it occurs. This means if the hazard does occur, what are the consequences? How badly will a plane be destroyed if it crashes, how seriously will a person be injured or will they die, how severely will equipment be damaged or destroyed? You could assign a numerical value to severity as well on a sliding scale of zero to 100 percentage, meaning that none, some or all of the aircraft, person, property or equipment is damaged, injured, destroyed or killed.

When you multiply the two factors of probability per cent and severity per centage together, the product becomes RISK, which is a real number. Risk is a product of two factors, meaning that each is factor is multiplied together to form a number. As when multiplying any two numbers between zero and 100 together, the product increases rapidly and in a hyperbolic fashion.

So I have written a mathematical formula to describe this and it is called, MILLER'S FORMULA FOR RISK. RIsk is labled Z, Probability is labeled X and Severity is labeled Y. When you multiply probability by severity you come up with risk. So the formula looks like this Z=XY. Plotting this function gives you a three dimensional display of the full range of risks. Factor in several more factors such as time and resources devoted to mishap investigations, called factor N and take into account some level of periodocity by looking at the trigonometric sine function and MILLER'S FORMULA FOR RISK becomes Z= sine |X| N(Y).

There is more in my paper published in the Flight Safety Foundation Proceedings of the 2003 Corporate Aviation Safety Seminar, entitled "Forecasting Hazards and Charting a Safe Course: How to Plan Changes in Flight Safety Programs to Meet Future Safety Issues, Decisions and Attitudes, and Keep Your Business Profitable!" copyrighted 2003.

If you have any problem getting a copy or a copy of the accompanying Powerpoint or would like me to come to your organization to speak more on this subject, contact me by Paulmiller@safetyforecast.com.

See other safety discussions on my web site: http://safetyforecast.com

Be safe. Remember that $afetyPay$