Bruce Mayes

Vintage Aviation

Bruce Mayes

The old adage, “Safety is an attitude” is more than a cliché.  Throughout the aviation industry everyone from every walk of life is trying hard to make the movement of people and goods by air as safe as humanly possible.  However, not everyone has an attitude which fosters safety, others beat the “safety drum” or wave the “safety flag” insincerely in an attempt to look as if safety is in mind.  This is illustrated in recent NTSB reports.

A Gulfstream IV crash on May 31, 2014 took the lives of seven people (among them David Katz, owner of the Philadelphia Inquirer).  The NTSB’s preliminary report raised issues about whether the crew had performed routine flight control checks prior to takeoff.

On the day of the accident, at about 9:40 p.m., the corporate jet crashed after a rejected takeoff at Hanscom Field (KBED) in Bedford, Mass.  The aircraft was unable to stop and overran the runway, hitting approach lights and a localizer antenna, finally coming to rest in a ravine outside the airport perimeter fence.  The post-crash fire killed all seven people on board: the two pilots, a flight attendant and four passengers.  The flight was operating under 14 CFR Part 91 as a corporate flight and was returning to Atlantic City.

The NTSB has determined the probable cause.  The Board concluded that the probable cause of this accident “was the flight crewmembers’ failure to perform the flight control check before takeoff, their attempt to take off with the gust lock system engaged, and their delayed execution of a rejected takeoff after they became aware that the controls were locked.”

A contributing factor was very disturbing.  The NTSB found “the flight crew’s habitual noncompliance with checklists”.  Other contributing factors are also noteworthy.  The Board stated that “Gulfstream Aerospace Corporation’s failure to ensure that the GIV gust lock/throttle lever interlock system would prevent an attempted takeoff with the gust lock engaged, and the Federal Aviation Administration’s failure to detect this inadequacy during the GIV’s certification.”

The crew was a well-trained senior and experienced pair of pilots.  The pilot-in-command, 44 years old, held an ATP certificate with single and multi-engine airplane ratings and type ratings for the BE-400, GII/III, Learjet and MU-300, as well as the GIV.  At his last medical, about a month before the crash, he reported 11,250 hours.  According to information in the NTSB accident file, the captain was “associated with the accident airplane owners for approximately 12 years, about 8.5 years in the GIV”.  The copilot, 61 years old, was an even more senior and experienced pilot, working for 27 years with the airplane owners.  He held an ATP with single and multi-engine airplane ratings and type ratings for the GII/III, JetStar and GV, as well as the GIV.  He also held a flight instructor certificate with single and multi-engine airplane, and instrument airplane ratings and an A&P mechanic certificate.

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The NTSB Board determined that during the accident flight, the crew failed to discuss checklists and failed to perform a flight control check.  It further determined that the crew failed to perform complete flight control checks on almost all of their last 175 flights.

According to the NTSB: “The flight crewmembers’ total lack of discussion of checklists during the accident flight and the routine omission of complete flight control checks before 98 percent of their last 175 flights indicate that the flight crew did not routinely use the normal checklists or the optimal challenge-verification-response format.  This lack of adherence to industry best practices involving the execution of normal checklists and other deficiencies in crew resource management eliminated the opportunity for the flight crewmembers to recognize that the gust lock handle was in the on position and delayed their detection of this error.”  It seems that not only was this accident fully preventable by use of a routine checklist, but that the crew likely never used checklists, since the investigators found that the crew did not perform complete flight control checks on 171 earlier flights.

How does a highly experienced crew end up with a habitual failure to comply with checklists?  How does that happen?  Checklists are the foundation of the standardization process that preserves safety in aviation.  They are particularly critical during taxi, takeoff and other high-stress activity when attention to detail is especially critical.

Understanding Hazardous Attitudes is the most common method for pilots to keep safety in mind and manage the risks posed during flight.  Whether commercially employed or privately flying, studies show that a pilot with a positive safety attitude is more likely to avoid an accident or incident.  A number of hazardous attitudes exist in aviation.  Officially there are seven; the most common are:

Anti-authoritarian – This is not uncommon.  We all known someone who chooses not to follow procedures, or breaches regulatory requirements as a matter of course.

Impulsive – The person who, for whatever reason, feels compelled to ‘do something instantaneously’.  We have often observed someone taking an instant course of action (either in the cockpit or in perhaps performing maintenance) without having considered all the options.

Invulnerability – The person who thinks his/her action could neither cause nor contribute to an aircraft accident.  Pilots who read this and other safety articles and think that only low-time pilots are the culprits…not themselves is one such example.

Exhibitionist – The show-off … no explanation required here.

Resignation – The pilot who conducts him/herself in a way so as not to disappoint others.  This attitude is not often recognized as a hazardous attitude.

So what can we do from an organizational perspective to deal with this situation?  Whether you fly for a commercial organization, flight school or for yourself, it is important recognize and mitigate these dangerous behaviors.

Some tips:

  1. Scope hazardous attitudes into your SMS

Human factors should be an integral part of the hazard and risk review.  As part of the organization’s employment controls, management should be asking themselves, ‘What mitigations can be implemented to minimize the probability of becoming associated with, or employing, personnel who have a hazardous attitude?’  Integrating SMS with human resource procedures would be an effective strategy.  If you suspect that a pilot, employee or associate possesses a hazardous attitude, investigate measures which prevent the tendency from materializing in the individual’s decision-making process and subsequent risky behavior.  Mentoring, coaching or including attitudes in the regular safety meetings, might be considerations.

Additionally, management should take all reasonable steps to encourage employees to confidentially report or discuss observations or concerns regarding hazardous attitudes within the organization.  Be sure you have a plan for dealing promptly and justly with individuals concerned.  We should also remind ourselves that individuals (and groups) can be conditioned and influenced to act responsibly despite the existence of a hazardous attitude.  Hazardous attitudes should not necessarily be considered evil or alarming, but rather as an intolerable human factor that needs to be managed appropriately within a proactive safety culture.

  1. Training

Training is central to providing employees with the skills, knowledge and willingness to behave in order to determine and maintain appropriate safety margin.  So why not consider hazardous attitude training within the organization or in the flight-training environment?  Unless you understand it, it’s unlikely you will be able to identify it and thereby eliminate it.

  1. Operational mitigations

Items 1 and 2 are preventative measures in that they act to suppress hazardous attitude.  However, what if the defenses fail and an individual commits an unsafe act?  An SMS can specify measures which seek to recover or control the potential consequences.  These include the interaction of technology, or perhaps the intervention of a second crewmember through CRM practices.

A positive safety attitude is not a cliché.



Posted in GACH, Newsletter.

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