Thursday, 20 June 2019


We have all learnt about safety management systems (SMS) and the 4 principal components - Safety Policy & Objectives, Safety Risk Management, Safety Assurance and Safety Promotion. Buried in Safety Assurance, within the sub-element Safety Performance Monitoring & Measurement are things called safety performance indicators or SPIs.

Most organisations have actually defined SPIs and slavishly track them at SAG and SRB meetings. But many don't really understand what SPIs are and what they should be doing for the business, so actually a lot of the effort is wasted on meaningless data.

Take a look at the diagram below - see how it shows SPIs as the very foundation of an integrated safety management plan:

Gates Aviation offers a one-day training course for aviation organisations, which clearly explains and demonstrates how to set useful and effective SPIs (and KPIs) that really answer the question:

"How good is our safety performance?"

Tuesday, 9 April 2019


The steering wheel of my old Reliant Scimitar motor car once came off in my hands while I was driving. That was certainly unexpected and the people who sold it to me would probably have said it couldn’t happen. But it did, and I had to figure out how to steer the vehicle while stopping in a safe (ish) place. I got lucky I suppose.

My thanks to Skybrary for - a summary of the Preliminary Report on the investigation into the crash of B737 MAX 8 on 10 March 2019.

The way I read this summary (and I’m sure I’ll be corrected if I’m wrong), the aircraft was technically flyable, although not in a way the pilots had ever seen before and certainly not in a way they had trained for. In fact, they did manage to fly it for a while, overcoming the efforts of the automation to pitch the aircraft down into a suicidal dive, by nose-up elevator and electric stabiliser trim inputs. But eventually it won…

If we go back 10 years to AF447, the pilots were also presented with something they had never seen and had never trained for. The aircraft was technically flyable and operated to design but they couldn’t work out what was happening and correct it. The Air Asia A320 that crashed in 2014 was flyable, although the captain’s well-intentioned actions had caused the flight control systems to revert to ‘alternate law’. The pilots would have seen alternate law in the simulator but never with a sudden and unexpected onset.

I would be prepared to stake a substantial bet that each of these crews could have easily and competently managed an engine failure on the preceding take-off (and any other take-off). That’s what we have trained them for. But these other random, unexpected and potentially startling conditions are not trained and are therefore far more difficult to manage, just like my steering wheel incident.

So perhaps it is time be a bit more imaginative and a bit less optimistic when designing flight training profiles and show pilots some more extreme and unusual flight conditions.

Wednesday, 2 January 2019


The following bullet points are taken from the investigation report on a fatal turboprop accident in Nepal in 2017. The sad fact is that all of the listed operator deficiencies could easily have been identified and rectified in advance. No need for people to die and aircraft to be destroyed...

Think about getting a fresh and independent pair of eyes to review your operational safety performance.

My thanks to Skybrary for the text.

Friday, 13 July 2018


You know how it is. Introduced to a complete stranger at a polite drinks party, once you have exhausted the pleasantries, one of you is going to ask "What do you do then?" My wife has taken to interjecting with "He's a pilot", which was once true of course, because she has grown tired of watching me struggle to explain what I actually do. With a little time to think, here are some of the things I have done in the last couple of years:

Written and presented a course on Compliance Monitoring to an airline in Nepal, which almost unbelievably operates helicopters to Everest Base Camp as a routine, and exceptionally up to Camp 2 in emergencies;
Closely engaged with an ambitious and rapidly expanding airline in the UK, helping to develop an organisational culture which embraces the concept of a Management System as defined in ORO.GEN.200;
Spoken on the merits of procedural compliance at the Eurocontrol Safety Behaviours Forum in Brussels;
Run a human performance and error management workshop for a large group of anaesthetists at a hospital in Essex - interestingly they invited me to observe the teams in action for two days in live theatres ahead of the workshop, to better understand their work (challenging for someone who doesn't do blood very well);
Conducted an audit of a UK operator's management system, using the new EASA Management System Assessment Tool for the first time;
Acted as an expert witness in flight operations and safety in a European airline's defence against injury claims (all successfully to date);
On the subject of expert witnesses, I have developed and delivered a course on how to present expert evidence (see below);

Lukla, NEPAL
Delivered Safety Management System initial and recurrent training to another Nepalese operator - this one ferries thousands of trekkers each year in and out of Lukla, gateway to Everest and one of the world's more challenging destinations;

Led a safety review of an extreme aviation sports portfolio in the Middle East - skydiving, paramotors, gyrocopters etc;
Delivered Upset Prevention & Recovery Training (UPRT) to a group of flight instructors in Lithuania;
Presented seminars on Evidence Based Training to operators and industry professionals from around Europe and Africa;
Trained departmental Risk Champions for a UK operator;
Developed and directed several emergency response exercises;

You see why my wife says I'm a pilot...

Thursday, 28 June 2018


Are you an expert in your field? If you are there is some possibility that you may be asked to act as an expert witness in a court case or arbitration. While you no doubt know your own subject very well, the first time you prepare written evidence for the court and your first physical appearance in the witness box can seem quite daunting. Firstly, there are strict rules around the instruction of experts. Secondly, court procedure can be rather confusing. And finally, an experienced legal professional is going to do his or her best to dismantle your evidence and discredit your expertise.

Gates Aviation has recognised this challenge and recently launched a familiarisation programme for prospective expert witnesses. This consists of a four hour face-to-face training session with a seasoned expert witness at a location of your choice, and an escorted visit to court when experts are giving evidence. It doesn't matter what your field of expertise, this is all about delivering evidence rather than what's in it.

If you want to be confident that your evidence is compliant and that you know what to expect in court, contact Gates Aviation to discuss this programme of expert witness preparation.

Tuesday, 17 April 2018


During audits and safety meetings I have often been asked ‘what are your top 5 risks?’ I have a problem with that question…

Let me start with a closer look at how the aviation industry historically quantifies ‘risk’. Once the system identifies a ‘hazard’ in the operating environment, we reach for a risk matrix of some kind – typically based on the 5 x 5 example described in ICAO Doc 9859, the Safety Management Manual. You know the one: ‘severity’ along one axis and ‘probability’ along the other.

I don’t really have a problem with the severity scale; it seems quite reasonable to imagine what the ‘worst case feasible outcome’ of the hazard could be and attach a severity in relation to the word pictures associated with the scale. But what about probability? Across the scale you will usually see 5 possible choices ranging from ‘very likely’ to ‘very unlikely’ or similar. What do they mean? If you look in the dictionary for ‘likely’ it will say something like ‘such as well might happen or be true; probable’ but that won’t mean a lot to a risk assessor. To help we tend to develop simpler word pictures to try and make the choice easier and more consistent or we might add a mathematical probability like ‘once in 10,000 flights’.

The trouble is that, once we have accepted that there is a probability of greater than zero, we need to be prepared for the outcome to happen at any time. Even if the probability is once in 10,000,000 flights, that accepts that it could occur on the next flight or the 10,000,000th one, or anywhere in between. So for any activity that we propose to repeat indefinitely, like going flying, we must accept an inevitable occurrence whatever the probability.

Can I tell you what my ‘top 5’ risks are? No. While each of my identified hazards may have differing probabilities, they do have a probability and I don’t know which is going to happen next.

Wednesday, 29 March 2017


A British national daily among other media outlets has been running with a story that a Bombardier Challenger business jet encountered wake turbulence from an Airbus A380 over the Indian Ocean. The story says that the encounter was so severe that the bizjet was rolled inverted and lost 10,000 feet in altitude. Photos of the cabin interior show total devastation and when the aircraft was diverted to Muscat, Oman, some passengers were taken to hospital.

But wait a minute, the A380 has been in service for over 10 years and there are now more than 200 of them criss-crossing the skies every day. Much of the world's upper airpsace is operated on reduced vertical separation minima (RVSM), meaning that vertical separation between opposite direction aircraft is 1,000 feet.

So why hasn't this happened before? We know that the A380 has a higher wake turbulence category but if it was dragging around vortices capable of inverting a sizeable business jet, surely there would have been more severe wake turbulence reports by now?

Or perhaps there is something we don't know...