Safety of Commercial Air Travel During the COVID-19 Outbreak

A guest post from Gates Aviation Associate John Edwards:

All international travel involves the risk of exposure to coronavirus at present. This risk can be managed in several meaningful ways but absent a vaccine, the final outcome of infection cannot.    

The manner in which COVID-19 spreads and infects people is an emerging issue. It is generally agreed that the disease can spread person-to-person through small droplets from the nose or mouth of an individual infected with COVID-19 and that coronavirus can remain intact and viable for up to 72 hours on some surfaces e.g. steel. It is unlikely to be spread through aircraft air circulation systems.

Operational recommendations for the aviation sector for implementation until the disease outbreak has been “closed”, have been provided by multiple international agencies. Sovereign States and their airports are categorised into risk levels although there are differences of opinion as to which level some States should be in. Risk level definitions vary but generally range from 1 to 3 where three recommends against all non-essential travel. A separate categorisation process is in place for State preparedness to manage the disease. These levels range from 1 (not prepared) to 5 for countries that have “more than 80% (medical response) capacity”.

  

Many airports are closed or have severe restrictions in place. The nature of airport design means that maintaining social distancing for staff and passengers can be problematic at best. The number of unavoidable physical ‘touch-points’ is vast and these are touched multiple times by a very wide range of passengers, airport employees and contractors. Previously acceptable airport cleaning regimes are no longer adequate. Specific types of waste must be categorised and disposed of a ‘biohazardous’.  

Airlines are similarly recommended to put special measures in place to minimise risk and protect passengers and crew to the greatest extent reasonable.   

In the same way that some aircraft operators and airports expect and implement higher standards of safety and security than others, performance differences can be anticipated in this regard too.

If a traveller develops COVID-19 symptoms whilst overseas he/she may need to be repatriated by specialist jet air ambulance. Travel on a commercial aircraft will not be an option.

All of this means that deciding whether to travel of air, where you can travel and whether it is relatively safe to do so is a complex task. Discharging corporate due diligence under these circumstances is markedly more difficult than usual.

Gates Aviation has current experience of doing exactly this and stands ready to help! 

SEE & AVOID - A SOUND COLLISION AVOIDANCE STRATEGY?

ICAO standards and consequently most regulatory jurisdictions state that pilots have an obligation to be ‘vigilant’ so as to see and avoid other aircraft – here is an example:

US FAA Regulation 14 CFR Part 91.113 (b) states:

…vigilance shall be maintained by each person operating an aircraft so as to see and avoid other aircraft

In many ways this has come to be seen as the last line of defence in collision prevention but we know that it fails. We need to understand why this is – what are the limitations to see and avoid?

Firstly, there are significant physical obstructions to a pilot’s line of sight, in the shape of the aircraft’s own structure. In fact a pilot’s field of view as permitted by the size and shape of the cockpit windows, only constitutes a small portion of the total sphere of airspace around him or her. In some aircraft the wings may also present a further external obstruction to their view. Moving one’s head may help mitigate for things like window posts but nothing will permit observations below, above or behind the aircraft. Pilots must understand that these are effectively blind spots to any see and avoid strategy.

We are well aware from eyesight tests that human vision varies substantially from one person to another. It is also true that an individual’s own visual acuity can vary with time of day, fatigue, light conditions etc. Those of us of a certain age also know that our eyesight deteriorates with the passing years… The likelihood of actually seeing a conflicting aircraft, even if it is within the field of view, is highly dependent upon the visual acuity of the observer and there is no consistent means to predict that.

We also know that the sensitivity of the retina varies across its surface. The point at which the lens focuses the image, the Fovea, is the most sensitive to colour and definition but this diminishes as distance from the Fovea increases. Our peripheral vision, what we see ‘out of the corner of the eye’ is relatively insensitive and is actually best at detecting motion across the arc of vision. This is recognised in the design of road traffic signals, which use not only a change of colour but a change of light source position to attract our attention – rather like the wig-wag lights on taxiways.

Another inherent visual factor is empty field myopia. At rest or in the absence of something to focus on, our eyes focus at approximately half a metre distance. This means that when looking at an empty sky, we may inadvertently be focused much too close and thereby compromise the ability to see another aircraft in the distance. Other effects like dirt on the windscreen can ‘trap’ the focus of the eye. It may be necessary to deliberately choose objects in the distance to draw the focus out to where the targets might be.

Pilots will be familiar with the effects of glare from a low bright sun – it is quite simply impossible to look in that direction let alone search for aircraft. Fighter pilots have always taken advantage of this to attack ‘out of the sun’. To make it worse pilots may be tempted to use sun visors or even charts and newspapers to block out the glare, thereby increasing the area physically blocked from view. Glare may also interact with atmospheric effects like dust, haze, mist and precipitation to increase their effect on the prevailing visibility. Whilst we know that VFR includes 5 kilometres of visibility, this can vary dramatically in different directions with the atmosphere and the light. 

See and avoid may not be so hard if all we had to do was look out of the window. Unfortunately, or perhaps fortunately, pilots have many other things to do and cockpit workload often increases in the same places that traffic density increases. This allows less and less time for looking for aircraft precisely when there may be more to see. As with all cockpit activities pilots must be careful not to become so absorbed with one task as to forget to carry out another task, such as looking out.

There are a number of techniques recommended for more effective visual scanning. As well as moving the head, pilots can divide the field of view up into segments and scan each in turn in a systematic fashion. In the case of 2 pilots they might choose to search their ‘half’ of the sky. Focusing on objects in the distance may help avoid empty field myopia. Operators should research the various scan techniques and train the ones most suited to their operation and environment.

Finally let’s look at a couple of characteristics of distant visual targets. Firstly, the diagram on the left demonstrates that geometrically an aircraft on a collision course will maintain the same position in the field of view as it gets closer. This means that there will be no angular movement of the target across the field of view and therefore our peripheral vision will be less likely to detect it until it is very close. The aircraft that is going to hit you may be the hardest to see.

On the right is a diagram that shows the visual arc described by an aircraft closing head on. This model is based on a closing speed of 600 knots but even if we halve that, it indicates that a target may only describe an arc of half a degree in our vision, when only 6 seconds from impact. It is still only 1 degree at 3 seconds, when the ‘avoid’ part is out of the question.

SPECIAL CONDITION FOR VTOL AIRCRAFT - EASA's EXPLANATION

Why a Special Condition?

EASA has reviewed more than 150 VTOL project configurations, at different stages of maturity, all aiming at addressing a potentially new market. The available data shows that there are a wide variety of configurations with limited common characteristics except for a VTOL capability and distributed propulsion. Despite having design characteristics of aeroplanes, rotorcraft or both, in most cases EASA was not able to classify these new vehicles as being either a conventional aeroplane or a rotorcraft as covered by the existing certification specifications.

Applying either the certification specifications for aeroplane or for rotorcraft, depending on whether they are rather an aeroplane or rather a rotorcraft, and only adding some modifications would not ensure equal treatment. These new types of vehicles are designed to address the same new market – even though not always the same segments. However CS-23 and CS-27 have significant differences, especially in terms of system Safety Objectives and Operational aspects. EASA opinion is that it would not be fair to treat applicants differently based on the regulatory starting point (CS-23 or CS-27) as it would probably favour some configurations, thus preventing potentially innovative concepts to compete on the market.

Instead, EASA favours to use objective based certification requirements, which provide the necessary flexibility to certify innovative state-of-the-art designs and technology, to establish a common set of conditions for the certification of these new concepts. Therefore EASA developed this VTOL Special Condition extensively based on CS-23 Amendment 5, which is also largely harmonised with the FAAs Part 23, integrating elements of CS-27 and new elements where deemed appropriate. Accepted Means of Compliance (AMC) will be developed and, when considered necessary, the most significant ones may be consulted publicly.

The establishment of a common set of conditions will enable a fair competition and clarity for future potential applicants. In addition, it will enable EASA to consider all vehicles with a Certification Basis based on the VTOL Special Condition as “Special Category” aircraft. This classification will provide greater flexibility in the Operational regulatory framework by enabling to tailor requirements to this type of aircraft rather than having to use aeroplane or helicopter regulations. 

SAFETY PERFORMANCE INDICATORS... WHAT?

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?"

PILOT TRAINING - ARE WE GETTING IT RIGHT?

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 https://bit.ly/2ImYXYY - 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.

WHY DO WE HAVE TO WAIT FOR A FATAL ACCIDENT?

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.

RISK & PROBABILITY

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 10,000,000^th 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.

A380 WAKE TURBULENCE AND CHALLENGER BIZJET UPSET

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...

COGNITIVE DISSONANCE - a factor in 'Pressonitis'?

Firstly I should make it clear that I am not a psychologist, nor in the truest sense of the word am I a scientist, although as an aviator I have a broad understanding of a lot of science. My knowledge of this topic in particular comes from extensive research into why pilots were flying approaches to land - the ‘approach’ being the last part of the flight descending towards the runway - when all of the available evidence indicated that the landing could not be achieved either safely or in compliance with operating procedures. The approach trajectory was either too steep or too shallow, the aircraft was too fast or too slow or the landing gear and flaps were not in the correct configuration. Pilots’ standard operating procedures required them to execute a ‘go-around’ in such circumstances, to abandon the approach, climb away safely and start again but some were simply not complying. This ‘unstable approach’ phenomenon as it is known, has been one of the most common contributory factors in commercial aviation accidents over the last 30 years or more but the tendency to press on in spite of the evidence is not unique to pilots.

This brought me to the work of Bluma Zeigarnik, a psychologist and psychiatrist born in Lithuania at the turn of the last century. She is probably best known for studies inspired by her Professor’s observation that a waiter appeared to have a much better recollection for orders that had yet to be paid for, than those which had already been settled. The waiter’s workflow involved taking the order, delivering the food and drinks and finally taking the money, at which point the workflow would be finished. He stored the order in his memory until the customer had paid and then subconsciously dumped it. In other words an incomplete pattern of work held a much higher priority for retention in the memory than one which was effectively completed.

Zeigarnik went on to study school children learning in class and found that those who were interrupted in the course of their work remembered more, and more accurately, than those who were allowed to finish without interruption. In isolation that is interesting but doesn’t tell us a great deal. However, Zeigarnik and her successors have shown that the increased memory retention is attributable to a heightened level of cognitive arousal whilst a task is being conducted, which is replaced by a more satisfied lower arousal once the task is successfully completed. The heightened cognitive arousal was in turn attributed to a degree of discomfort that the goal may fail, discomfort that could only be assuaged by success. Nowadays we know this as the ‘Zeigarnik Effect’. To take it one step further, research suggested that humans remember bad things more clearly than they remember the good things; perhaps from a survival perspective this makes sense – we remember what has done us harm so that we can avoid it in future.

So finally, the outcome of this ‘cognitive dissonance’, the disparity between aspiration and reality during the conduct of a task, is that we humans harbour a compelling desire to complete a task once we have commenced it. This can be so compelling that we may press on although all of the indications, our instincts and maybe even our own colleagues are telling us to stop and rethink the strategy. This is what we found with the ‘unstable approaches’ continued to landing – pilots had become so focused on achieving the goal that they were able to ignore the evidence that it was failing – and it probably applies to many other aspects of professional and personal life.

AIR CRASHES - 3 DIFFERENT THINGS – BUT ARE THEY CONNECTED?

The first of these three things I have mentioned in this blog before. I spend a lot of time taking apart fatal aviation accidents, looking for the influences and factors which came together in the unique combination that allowed each ‘accident’ to happen. In recent years one of the most common precursors to a crash is procedural non-compliance – deviation from standard operating procedures by one or more of those involved. The reasons that pilots and other professionals deviate in this way are many and often related to complex human behavioural conditions; it is worth looking at Abraham Maslow’s hierarchy of human needs for insight into some of them. Whatever the underlying reasons, prior to a crash the captain will frequently decide to do something contrary to their training and procedures, that will eventually lead to their own demise. Sadly their co-pilots often look on, aware that all is not well but saying nothing.

The second thing is ‘risk denial’; maybe I have raised it in earlier posts. This is a condition that arises when we are regularly exposed to a particular, perhaps severe, hazard but it never actually does us any harm. Over time we may subconsciously adopt a mind-set that whilst the severity could be very high, the probability or likelihood is so low that it can be disregarded. Imagine passing a heavy truck in the opposite direction on a narrow lane – the obvious action would be to slow down and pull in to the side of the road to let it pass safely but every time you have passed a truck no harm has come of it. So you are able to ‘deny’ the risk, despite its blatancy, and drive on as normal with a metre or less between you and death.

So here is the final thing and I wonder if there is a connection between the three? Modern movies, TV shows and most significantly computer games allow us to experience horrifically dangerous and deadly situations without suffering any (other than perhaps psychological) harm. Could that have led to a general conditioning of westernised humanity (including pilots) to be able to subconsciously ignore hazards and adopt risky behaviours on the assumption that we will come to no harm however bad things look? After all, passengers now routinely collect their baggage before evacuating an aircraft, despite the high risk of fire and explosion. I don’t know…

WHY NOT DEBRIEF?

After every mission military pilots and their crew will hold a debrief to discuss want went well and what could have been done better. This is an opportunity for those involved in the task to recognise superior performance and to learn by addressing any deficiencies – makes sense right?

However, post-flight debriefs in commercial aviation are quite rare, in spite of the obvious potential value. In many regulatory jurisdictions pilots and cabin crew are only considered to be ‘on duty’ until 30 minutes after ‘on-chocks’ time so there is a limited window of opportunity. Furthermore, the crew for the next scheduled flight will frequently be waiting to get on board to maximise preparation time during the short turnaround period. Perhaps most influential is the fact that it isn’t ‘the way we do things around here’ – it’s not part of the culture.

A pilot would think nothing of remarking on a colleague’s smooth landing in difficult crosswind conditions for example but there is unlikely to be much discussion about it if it went less well. The absence of a debrief effectively implies that the entire flight proceeded satisfactorily and in accordance with standard operating procedures: there were no errors, deviations, distractions and consequently no opportunities to learn. Any pilot knows that is never the case but without a professional conversation immediately afterwards, the implication becomes reinforced.

Pilots are well used to debriefs after training flights so why not after every flight?

MORE ON CULTURE

'Culture', a term we hear used a lot in aviation these days; organisational culture, reporting culture, safety culture, just culture... You name it, there's an applicable culture. But what does it mean?

If you look it up in a dictionary it will say something like 'common behaviours and beliefs shared by a group', and offer examples such as youth culture or drug culture. Alternatively you might hear it described as 'the way we do things around here'. These definitions imply that everyone in a group does certain things the same way, so how does that happen?

An example that comes to mind relates to the flashing of car headlights. Here in my native England, if someone else flashes their headlights at me I understand it to mean 'go ahead', and so does just about everyone else. However, I spent 17 years resident in Dubai, UAE, where flashing headlights means (emphatically) 'get out of my way!' One step further, if you are lucky enough to experience the joy of driving in Nairobi, Kenya, you will find a more complex flash-code. One long flash equates to 'don't go there', whereas two short flashes means 'please go ahead'.

Now nowhere are these 'languages' written down but you can see that failure to assimilate them quickly could result in an unpleasant outcome - we humans are fast learners when it comes to survival. That is the way they do things around here and so we will do it too. An important lesson in culture; we tend to emulate those around us, whether we think it is right or wrong.

As a post script it is worth considering the likelihood of misunderstandings as a result of modern automatic headlight systems.

PILOTS MUST THINK LIKE THEIR AEROPLANES...

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’…

HEALTH-CHECK YOUR SAFETY CULTURE

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 .

ORGANISATIONAL SAFETY CULTURE HEALTH CHECK Score 1 for ‘True’, 0.5 for ‘Part true’ and 0 for ‘False’
Statement	True	Part true	False	Score
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: