Tuesday, 6 September 2016


So the preliminary findings of the investigation into the Boeing 777 that crashed on landing in Dubai in August are that the pilots touched down ‘long’ and elected to initiate a ‘baulked landing’ manoeuvre, presumably to reduce the risk of an overrun. Baulked landing is very similar to a go-around – press the TOGA (take-off/go-around) switches to automatically increase thrust (the 777 has two levels of thrust response depending on the number of presses), partly retract the flap and once climb is established raise the gear. However, with wheels on the ground the TOGA switch thrust response is inhibited so for a baulked landing the pilots must advance the throttles manually. A subtle but crucial difference, which if not practiced regularly, may be overlooked in the heat of the moment.

Automation has all sorts of benefits in modern aircraft but due to the very wide range of operating environments and manoeuvres, it has different regimes of logic for different phases of flight. If these regimes are not fully understood, together with the conditions that bring about the transition from one to another, then the automation and hence the aircraft, may not respond as expected. This is not unique to Boeing and Airbus aircraft have suffered accidents for similar reasons. Today’s pilots must learn to ‘think like their aeroplane thinks’…

Monday, 5 September 2016


This is a bit of fun but it also has a serious side - give it a try and see how your organisation fares. We put it together to give you the opportunity for a bit of honest self-analysis of the culture with regard to safety and risk in your business. It doesn't purport to be a comprehensive analysis but it should give you an insight into how things are going.

If you come out with a score of 15 - 17 things are probably going pretty well but less than 10 could indicate that you have some systemic cultural and/or organisational safety issues which need to be addressed. At Gates Aviation we have a collaborative and realistic approach to resolving these issues without turning the business on its head. Give Sean Gates a call on +44 (0)207 4696437 or e-mail sgates@gatesaviation.com .

Score 1 for ‘True’, 0.5 for ‘Part true’ and 0 for ‘False’
Part true
The organisation has a clear safety policy:
There is a policy statement with respect to safety and risk, that is written in simple and clear language, agreed by senior management and signed by the CEO/MD/Accountable Manager

The safety policy reflects reality:
The terms of the policy reflect the genuine intent of the organisation’s management with regard to the safety of people, property and the environment

The organisation has clear safety objectives:
There are a number of clearly stated and generally SMART safety objectives (2-6), which reflect the specific goals of the organisation with regard to safety and risk

The safety objectives directly support the safety policy:
There is a recognisable link between the goals stated in the safety objectives and the intent implicit in the safety policy

Safety activities and initiatives directly support the objectives:
The allocation of resources, the activities of the safety department and the safety initiatives of the organisation demonstrably support the objectives

The safety objectives are widely known and understood:
Most personnel, especially those in front line safety critical roles, can articulate at least the intent of the safety objectives

The safety objectives have meaningful performance indicators:
Each safety objective has one or more metric or performance indicator (SPI), which genuinely measures the organisation’s progress with respect to that objective

The performance indicators have valid targets:
The organisation has defined realistic and achievable targets for each SPI, and there is a process to review the targets regularly

Performance in relation to targets is regularly reviewed:
Senior management has a process to review safety performance as indicated by the SPIs and the achievement of targets

Failure to meet a performance target is examined at senior level:
Failure to meet a performance target in the allocated time is analysed by senior management and the reasons for failure identified and addressed

Safety performance data is shared throughout the organisation:
Safety performance as indicated by the SPIs and targets is disseminated to all personnel in an appropriate and understandable format

Reporting of safety incidents and accidents is a requirement:
All personnel have an explicit and contractual obligation to report safety incidents and accidents via an established safety reporting programme

Reporting of hazards and near-misses is encouraged:
Personnel understand what constitutes a hazard and a near-miss in safety terms and are positively encouraged to report them

Incidents, accidents, hazards and near-misses are investigated:
There is a documented process to ensure that reported safety issues receive an appropriate level of investigation by trained safety investigators

Reporters are treated fairly:
Originators of safety reports are treated in a fair and consistent manner, are assured of an appropriate degree of confidentiality, and always receive acknowledgement and feedback

Acceptable and unacceptable behaviours are clearly defined:
There are documented definitions of what constitutes acceptable and unacceptable behaviour with regard to safety and risk

Disciplinary processes are clear and consistent:
The consequences for an individual found to have behaved in an unacceptable manner with regard to safety and risk are clearly defined and always consistent

Total score:

Monday, 1 August 2016


The following is a 'guest post' from my Gates Aviation colleague John Edwards:

I have recently completed a risk assessment of the safety and security of an airline's crews, engineers and aircraft while operating in a high risk environment during the period of a proposed wet lease. The 'donor' airline was registered in a state that has, and the airline itself has embraced, a relatively high level of risk aversion.

 It is well known that there has been a longstanding history of terrorist attacks against commercial (and military) aviation in the location where the personnel and aircraft would be based and that numerous fatalities have resulted.

 The state authorities advise that that "all foreigners, may not move out of their city of residence without proper security and without prior coordination with the law enforcement agency". The approach taken to providing security in civilian life, especially in relation to what might be considered 'soft targets' e.g. selected public highways and shopping malls, was evident and likely to aid deterrence and detection (of terrorists and planned attacks). There was meaningful evidence to suggest efforts had been taken to harden these (previously soft) targets and protect the related communities.

 Security had been tightened at the state's international airports following a number of terrorist attacks in 2014 and further strengthened in 2015. A historic ban of locally registered airlines from operating into the EU for safety reasons had been lifted in 2015. ICAO and the USA consider that implementation of ICAO aviation safety standards in the state to exceed the global average. The airline with which the wet lease was proposed, is a member of IATA and therefore when last audited met the requirements of IOSA. Viewed in combination these facts provided evidence that the national aviation security and safety culture and infrastructure are widely considered to be sound. The main roads between the airports and hotels feature multiple manned checkpoints and the hotels where the crews and engineers were most likely to be staying, had robust security measures in place. The better quality shopping malls had entry search points operated by the military or other government agencies. It is known that places of worship and large public gatherings should be avoided and that periods leading-up to political elections can see increased civil tension and unrest. As in most business sectors and risk management environments, there was scope for continuous improvement to aviation security processes and procedures and implementation of best practices. But I considered existing measures to be relevant, adequate and sound. Accordingly, I concluded that subject to these measures being maintained, to the threat level not being raised to 'red' (the highest level) and to good situational awareness being exercised by operational personnel from the donor airline, when they are on site, the wet lease should not materially increase risk exposure. My assessment was that there are no substantive safety or security reasons why the proposed wet lease should not proceed as planned.

Wednesday, 27 July 2016


Human performance deficiencies were identified in the investigations of all 11 accidents and human factors overwhelmingly dominated the lists of causes and contributory factors. The study set out to analyze these deficiencies against two separate models, the Dupont ‘Dirty Dozen’ and the Pilot Competencies Model, as described at the outset. All of the accidents had identifiable factors from both models; indeed some accidents appeared to include deficiencies in virtually all of the Pilot Competencies together with many of the ‘Dozen’.

The graph below shows the number of accidents from the original 11, in which each of the markers from the Pilot Competencies Model was found to be deficient:

It is perhaps not surprising that the pilots in every accident exhibited deficient Situational Awareness – had they been more aware of the situation it seems likely that they would have taken more appropriate action to avoid terrain proximity. It is disappointing to see that the pilots in all accidents were also deficient in the application of their procedures but on the other hand this may be encouraging, in that procedural compliance is possibly indicated as a significant factor in the mitigation of CFIT risk. Poor communication was also identified in most (8) of the accidents, supporting a view that CRM (crew resource management) in general and communication in particular, are vital for the avoidance of CFIT.

The next graph illustrates the same data for the Dupont ‘Dirty Dozen’ markers:

Once again Lack of Awareness tops the table, appearing in all of the 11 accidents and reflecting the deficient Pilot Competency of Situational Awareness above. There is no Dupont marker that corresponds to the Pilot Competency of Application of Procedures so we can’t see a correlation but Lack of Communication again appears in the same 8 accidents. Lack of Teamwork and Lack of Assertiveness were identified in over half of the accidents and these two markers are in some ways related. If the Captain in particular is not a ‘team player’ and fails to respect colleagues and their opinions, the FO may become isolated and feel unable to intervene, even to save their own life. This risk is exacerbated by a steep authority gradient in the cockpit. Norms featured as a marker in almost half (5) of the accidents, when pilots developed and employed their own processes, either when they found that the promulgated process was inefficient, ineffective or difficult, or when there was no applicable process for them to employ.

Stress, Pressure, Fatigue, Complacency and Distraction each appeared in only 3 or fewer of the accidents but these conditions are sometimes difficult to identify from investigation reports. Unless the CVR records specific and attributable voice characteristics, or the individual mentions that they are affected by a condition, it may be that the condition goes unnoticed in the investigation.

It is worthy of note that neither model specifically addresses markers for Monitoring and/or Cross-checking, although Lack of Awareness and Situational Awareness respectively could be taken to include those competencies. Deficiencies in monitoring and cross-checking were apparent in several of the accidents. It is precisely these functions, functions we know humans perform quite poorly, that the EGPWS/GPWS/TAWS seeks to augment in CFIT prevention.

Finally, the graph below combines the two models to show the number of markers associated with each of the 11 accidents:

Accidents with a greater number of markers from one model also appear to have a similarly greater number from the other model – total markers per accident varied from 7 to 14 but the variation between models was never greater than 2. This may indicate that the two models identify similar human performance deficiencies but it may also be a reflection of the amount of information available from the accident reports upon which the study was based. These varied from a few pages to well over one hundred.

Friday, 8 July 2016


I saw this excerpt from a book on twitter today, written by a test pilot:

It reminded me of a different book written by the Australian Group Captain Doug Edwards many years ago. He wanted to explore the reasons why high-performing airmen like military display pilots sometimes died in accidents they could have escaped from. Why didn't they eject?

His conclusion was a product of Abraham Maslow's hierarchy of human needs (read about it in Wikipedia). This suggests that humans may fear loss of status and self-esteem just as much as they fear death. High performers can become 'addicted' to their status and will do just about anything to preserve it, struggling to rescue a hopeless situation beyond the point from which they can escape.

Maslow's Hierarchy of Needs

Thursday, 7 July 2016


Almost 30 years ago I was in the right hand seat of a BAC 1-11 narrow-body twin, on approach to Aberdeen. It was around 10 at night, dark, windy and raining - pretty standard stuff. We were on the last of 3 rotations to Heathrow and quite keen to get back to the hotel for a beer and some rest. And the captain had brought his wife along for the week detachment so she was waiting for him...

He was flying down the non-precision approach, with the landing lights glaring onto the clouds in front of the windscreen and the anti-collision beacon intermittently looming orange. At around 500 feet from touchdown I called 'minimum' as dictated by the SOP and there was certainly nothing like a runway in sight. The captain replied - I forget what he said but we continued descending as before and about a hundred feet later the runway lights appeared through the rain and we touched down uneventfully.

It was only later that it dawned on me what had happened - the captain had pressed on below minimum because he didn't want to divert. I was new to civil airline flying and new to the airline so wondered if that was how things were done around here. Of course I quickly learnt that it wasn't.

This all came back to me last week when I read about an A330 that landed off the side of the runway in Kathmandu. Apparently the pilots had trusted the accuracy of the aircraft's GPS based navigation systems enough to continue below the published approach minimum. Of course they were wrong.

To read about the outcome on Skybrary click HERE

Monday, 20 June 2016


I have spent a lot of time unpicking aircraft accidents in the course of my consultancy for IATA’s risk reduction programmes and as an expert witness in liability cases. Whilst that does risk becoming desensitised to the frequently unnecessary tragedy of these events, it has given me a keen insight into what causes pilots to crash their aeroplanes. Perhaps more importantly I believe it has helped me to distill some key factors which could have stopped them happening – three in fact, which I will explain below.

Prevention – generally we would all accept that prevention is by far the best means to avoid accidents, in the air or on the ground. We have countless opportunities to prevent accidents every day and in flight operations this activity is formalised into procedures and checklists. If we adhere to these tried and tested action sequences, the overwhelming majority of flights will be uneventful. Therefore, straightforward procedural compliance can deliver accident prevention virtually every time.

Recognition – in today’s highly reliable aircraft, operating in a well-controlled environment, facilitated by real-time weather, traffic and airspace information it is rare for anything out of the ordinary to penetrate the serene world of the commercial pilot. But if something unusual does happen it is vital that the pilots quickly recognise the deviation, picking it out from the backdrop of countless hours of ‘normal’. This ability to recognise the abnormal must be founded upon a comprehensive knowledge of what normal should look like; what is the acceptable range of values for every critical parameter.

Recovery – having recognised that things are not going to plan, pilots must be able to recover to normal, or at least to a new ‘normal’ within the constraints of whatever has occurred. Then and pretty much only then, do the pilots require real skill.

So that’s it; prevention through rigorous compliance, recognition based on comprehensive knowledge and finally recovery requiring piloting skill. Most of the current generation of airline pilots will probably never need more than the first of these (and that’s worth bearing in mind when hiring and training pilots) but how do we deliver and maintain the knowledge and how do we hone the skills when they may never be needed in the course of an entire career?