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! 

WHAT A GIRL (OR GUY) WANTS...

Looking at this representation of Maslow's hierarchy of human needs, would it be fair to say that most of us in the aviation industry (in the wealthy West at least) have taken care of the bottom 3 layers? We can probably expect to have food and shelter, a job with an income and some kind of family or community group to belong to.

If so, that means we are all principally motivated to a greater or lesser extent by a desire for RESPECT, RECOGNITION and STATUS. Why does that matter? Well it also means that those around us have similar motivations, and perhaps if we deliver them their needs they will probably deliver for us.

Worth a thought.

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’…

SAFETY & SECURITY AUDIT IN A HIGH RISK LOCATION

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.

HUMAN PERFORMANCE IN CONTROLLED FLIGHT INTO TERRAIN (CFIT)

The following is an extract from a research piece I did recently, which examined the factors involved in 11 controlled flight into terrain (CFIT) fatal accidents. This extract summarises the human performance factors and has some interesting findings:

Analysis of Human Performance Factors

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.

MASLOW AND HIGH PERFORMERS

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

APPROACH BELOW MINIMUM IN IMC - DON'T...

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

SAFETY RISK TROUBLESHOOTING

This year probably won't be the worst in aviation history in terms of accidents, hull losses or fatalities but it won't be the best either. Apparently sound air carriers with hallmark certifications like IOSA and the ISO 9000 family have still lost aircraft, crew, passengers and reputations in well known and researched event modes like runway overrun and controlled flight into terrain (CFIT). It isn't because they weren't trying to be safe either; no-one plans to have an accident - it wouldn't be an accident if they did.

Sometimes though it is possible for even the very best organisations to become so involved with the business of doing business, and staying in business in these difficult times, that they miss vital signs of inherent risk in what they do or what they are planning to do. That is when an independent view, the eye of the risk 'troubleshooter', is required to take a closer look and ask the awkward questions which might reveal the business or operational threats no-one is choosing to see.

Sounds dramatic? A bit sensationalist? Try the media and market responses to an accident or even a serious incident - they have a monopoly in those adjectives. Give us a call at Gates Aviation on +44(0) 207 4696437 and we can discuss a number of options, some of which could be entirely free of cost, to help you identify, measure and manage your aviation and enterprise risk.

IATA SAFETY REPORT 2009

The IATA Annual Safety Report for 2009, based on worldwide accident and incident data, offered some enlightening statistics as always. Firstly, runway excursion was the most frequent accident type in 2009 and it is no coincidence that IATA is revisiting its runway excursion risk reduction toolkit - I am fortunate to be contributing to that effort and will have more on the subject later. Even more striking for me was the finding that almost a quarter of accidents were attributed in part to deficient safety management, and that 86% of those implicated the regulator for deficient safety oversight. For a start I would refer to my earlier piece on the EC List of Banned Carriers, and suggest that the EC might have a point! Secondly, what does this say for the concept of safety management systems (SMS)? The whole idea of SMS is to allow operators an element of autonomy in safety management, free to some extent of prescriptive regulatory constraints, to allow them achieve the best standard in a way that suits their operation. However, if neither the operators NOR the regulators can be trusted to maintain adequate standards of operational and corporate safety, SMS is doomed to fail. We can't let this happen because it has been proven time and again that regulatory compliance does not equal a safe operation...

EUROPEAN COMMUNITY LIST OF BANNED CARRIERS

The 'Blacklist'

The EC list of banned carriers purports to safeguard EU citizens in 2 ways – one by preventing unsafe airlines from operating in Europe, and the other by listing airlines which may not operate in Europe but which EU citizens may consider using on their travels. However, there are some anomalies. For a start there is a perception (unconfirmed) that European governments regularly charter banned airlines for logistics associated with military operations, and secondly major multi-national companies (notably resource groups) often charter such carriers to move personnel in countries outside of the EU. In the latter case tragedy struck recently when several Australian business executives were killed in a crash in Africa, in an aircraft operated by a carrier which features on the list.

The intent of the blacklist is clearly a good one but what do you think about the reality?