Business Aviation Safety: Can risk-management training improve the industry's record?

Aviation International News » May 2006
September 19, 2006, 7:57 AM

The spate of high-profile business aviation accidents a little more than a year ago, many of which were Part 135 flights, has prompted industry experts to search for a link that might prevent the same events from happening in the future. There has been little public outcry for more government oversight because most consumers of corporate and charter aviation believe it probably already exists. The real question left to those in the industry is whether or not these accidents are an aberration or unsettling evidence of a flaw that runs deep.

The first accident happened during the arrival phase of a Part 135 positioning flight to pick up former president George H.W. Bush on Nov. 22, 2004. The Gulfstream III crashed three miles short of the runway while on an ILS approach to Houston Hobby Airport. Both pilots and the flight attendant were killed.

Six days later, a Challenger 600 operating on a Part 135 flight crashed on takeoff from Montrose, Colo. The captain, flight attendant and one passenger were killed, while the first officer and two other passengers sustained serious injuries.

Then on December 1 a chartered Gulfstream IV crashed off the right side of Runway 24 at Teterboro, N.J., after executing a circling approach from the Runway 19 ILS. The flight crew was unable to deploy either speed brakes or thrust reversers after touchdown. There were no injuries, but the aircraft was substantially damaged.

On February 2 last year, a Challenger 601 on a Part 135 trip ran off the end of Runway 6 at Teterboro during an aborted takeoff. The crew and passengers sustained minor injuries when the aircraft crossed an airport boundary road and crashed into a warehouse. An occupant of an automobile struck during the crash suffered serious injuries. A month later, after much oversight confusion about which company was actually responsible for operating the aircraft, the FAA shut down charter firm Platinum Jet.

In an ABC News story related to the Feb. 17, 2005, crash of a Part 91 Citation 560 near Pueblo, Colo., that claimed eight more lives, an FAA spokeswoman said the agency planned a meeting in Washington, D.C. to look at safety issues related to corporate jets and on-demand charters. She said the meeting, which took place on February 18 last year, had been scheduled before the Pueblo crash.

In May last year Forbes published an article that was highly critical of the air-charter industry. Unfortunately for business/charter aviation, the magazine’s 5 million readers could represent a significant portion of the potential or current operators of business airplanes.

The article, “Flight of Fear,” focused on what the magazine called an “alarming increase” in charter accidents that pushed the charter fatality rate up by 55 percent in one year. Forbes also claimed that passengers aboard a chartered jet are 18 times more likely to be involved in an accident than airline passengers.

Robert Breiling, president of accident analysis firm Robert E. Breiling Associates, disagreed with some of the data in the Forbes article in a letter to the editor. Breiling pointed out that while the accident statistics the magazine published were correct, they were “terribly distorted by the fact that the FAA and NTSB lump together all types of aircraft for hire including piston single- and twin-engine airplanes, as well as helicopters, rather than just turbine airplanes primarily used in charter.

“In addition, many of the commercial operations included in the FAA/NTSB statistics for Part 135 aircraft for hire involve high-risk operations such as emergency medical service, human organ transfers, cargo and check-hauling flights, all of which have a greater potential for accidents than passenger-carrying charter flights.

“The results of these distortions will lead your readers to erroneous conclusions about the safety of passenger-carrying charter flights. Charter has actually improved over the years. Part of the reason for that is that the good ones do more training. But it’s not the good ones that are having accidents.”

Additional statistics from Breiling show a total accident rate for Part 91 business jets of 0.210 per 100,000 flight hours in 1990. A partial year of data in 2003 shows that rate had dropped to 0.028. For Part 135 business jet charters, the rate in 1990 was 4.76 per 100,000 hours. That rate also dropped significantly in 2003 and stood at 2.50 by mid-year.

By combining the statistics of all for-hire operations, Forbes inflated the accident rate significantly. Breiling countered, “In 2004 there were 12 chartered business jet accidents, four of which involved 18 fatalities. This contrasts dramatically with the 65 fatalities reported in your article.”

This 2004 chartered business jet accident figure represents an increase of one accident and six fatalities over the previous year, noted Breiling, and certainly not the “alarming increase in accidents and deaths” that the article asserted. “By comparison, scheduled and non-scheduled air carriers suffered 24 accidents and 14 fatalities, actually more than double the number of accidents reported to involve chartered business jet aircraft.”

The method the FAA uses to gather aircraft statistical data that’s turned into accident data has also been called into question, most recently by the NTSB. The FAA gathers current usage numbers through surveys of a small segment of the industry. The NTSB contends that the system should be re-evaluated because the data is used as the basis for assessing general aviation safety and allocating resources in the U.S. The Safety Board has recommended that the FAA find new ways to track activity for Part 135 and Part 91K (fractional) operations, as well as to validate the information gathered.

Breiling estimates about 3,000 charter companies are currently certified to operate in the U.S. Better data would actually improve the overall safety record for almost all segments of aviation, he said, but he added that trying to change the way the FAA conducts business is difficult. An FAA spokesman disagreed: “We expect to double our fleet sample size from 30,000 to approximately 60,000. We are now sampling 100 percent of air taxis, rotorcraft, turbine-powered aircraft and Alaska aircraft. We also expect future surveys to be completed in a more timely fashion.”

Industry Self-regulation

Learjet’s Bob Agostino, who leads the Bombardier Safety Standdown in Wichita each fall, noted, “Even with all of the new technology in airplanes today, TAWS, TCAS and the rest, we’re still flying airplanes into the ground.”

Many insiders have begun to take a hard look at what the industry can do to improve the safety record for business aviation. Some said waiting for the FAA to take the lead would set an uncomfortable precedent. Andy Priester, president of Chicago-based Priester Aviation and chairman of NATA’s air charter committee, said, “People pay much more attention to safety than before. While no doubt the recent accidents have brought safety to the forefront, it is important that we be there with a plan to improve the safety culture throughout this industry.”

Last summer NATA debuted its new safety management system for air charter, which Amy Koranda, the association’s director of safety management, believes will help foster an improved safety culture in the industry.

“We did wonder whether we might not be preaching to the choir at some point,” Koranda said. “But we knew we needed to begin somewhere. The system works by examining risks and deciding how to manage them.”

“As an association,” said Priester, “NATA wanted to help raise the bar on safety by creating a system that is practical, manageable and usable.” For the new NATA system to work, he said, the plan needed “reasonable barriers of entry, low enough that anyone can participate. The new system was designed to examine, explore and improve safety. These concepts call for regular feedback and analysis from users,” he added.

Rich Kunert, director of quality assurance and safety for New World Jet, said, “The FAA has asked the air charter community for whatever help we can offer. Operational control of charter flights is a huge issue that the industry is looking at right now. And I think this industry is going to be asked to do a lot more on safety initiatives in the future.”

One issue is defining precisely the goals of any program. “There is an important difference between a safety culture and a true risk-management culture in any flight department,” said Tom Roberts, safety manager at the Navy’s Atlantic Wing Research, Development and Test Center at Patuxent River, Md. Roberts’s crew will be responsible for testing the new presidential helicopter, the US-101, before it enters service in 2009.

“A pure safety culture focuses on the things we already know, while a risk-management culture looks at the hazards we don’t know about before we face them. The question then becomes how we cope with this new hazard. We found that we really did not understand how our pilots actually thought through the risk-management process. We’re trying to find out now.”

NBAA’s safety management system offering is called IS-BAO, for International Standards for Business Aircraft Operation. IS-BAO is a system designed to build a safe flight department from the inside out through the use of the standards process developed by the International Business Aviation Council (IBAC). Ray Rohr, IBAC’s standards manager, explained an important element of the system. “Once people get involved in a safety-management system, they will help it evolve into a system that works for them.

“Our goal was to bring more discipline to the operational side of business aviation. Pilots who have taken part in IS-BAO certification no longer feel they have an option to fix a problem in their flight department; they believe they have a responsibility to fix it.”

Harold Clark, chairman and CEO of USAIG, explained some of the difficulties charter operators face. “Operators [under Part 135] feel constant pressure to put time on the airplane. Typically, charter operators fly 700 to 800 hours per aircraft annually, often outsource maintenance and fly older equipment.

“The recent group of accidents has focused our attention and we are working with the FAA to develop some best practices. Unfortunately right now, the FAA only asks for minimums of performance. And not everyone in the industry meets even those standards.”

Pilot Selection

In the move to reduce accidents further, Dr. Jerome Berlin, an aviation psychologist and pilot, has called attention to another area in significant need of work. “I think we’ve all been negligent in the pilot-selection process,” he said. “We select business aviation pilots based on the number of hours they have or their ratings. But do they have the quality dynamics to make a quality pilot? There are GA pilots out there right now who will never be low-risk pilots, no matter how much training we give them.”

Regardless of the criticism the airlines have taken for years about their often overwhelming choice of ex-military pilots to fill the cockpits, Berlin believes there was some solid reasoning behind those choices.

“The airlines knew these pilots had already achieved a certain level of discipline and had the kind of personality to deal with unusual circumstances, such as long periods away from home or fluctuations in circadian rhythm,” he said.

Berlin says that within almost every group of pilots he’s ever worked with at a flight department, “there are one or two who should not be there. Either personally or behaviorally, they should not be flying. But no one wants to get rid of them because they are afraid of being sued.” Berlin believes management must change, assuming they have the experience to recognize the problem.

Berlin believes that pilots tend to look less often at the interpersonal part of the world around them. “This is what often makes pilot groups within a company so difficult to manage,” he said. “Most other corporate employees work together, make group decisions and attend professional training together. Pilots tend to be loners by nature and profession. Managers need to look at pilots as people who also need to grow professionally, just like other employees, but in a different way,” he noted.

Pilots also need to realize that, whether they like it or not, they don’t operate in a vacuum, Berlin added.

Learjet’s Agostino sees the direction of business aviation safety improvement from a pragmatic cockpit perspective. “Corporate aviation is the only venue that thinks simulator training should be used exclusively. The military doesn’t think that, and neither do the airlines.”

A recent naval air training manual explains that pilots should use a simulator to maintain basic skills but adds that a simulator is no substitute for actual time gained in the real aircraft. Agostino said, “The entire simulation issue is out of balance. We have tried to replace our knowledge base of training with a skill base. And it doesn’t work.

“I’ve come to believe that while we once had a training cost problem in the accounting department or from the CEO, the real problem today lies within the flight department itself. Too many pilots just don’t think they need any extra training. Too many pilots believe they have reached a level of competency. But it’s really a level of complacency.”

Human-factors Training

Human factors are a significant part of any of the safety systems either in place or about to be implemented. Agostino said, however, “We have not really attacked the human aspect of the accident problems. And there isn’t simply one system that will fix everything. The most important element is to push the curve. Show me a recent business aviation accident that was caused by a mechanical failure. Pilots still believe none of this stuff will happen to them, but it does, over and over again.”

Human factors also means motivating everyone in the department, including managers, to strive to be better, no small task if those managers have never had training that helps them look for, much less see, solutions outside the box.

Berlin added that despite most aviators’ reluctance to acknowledge how they feel, “The emotional level is where learning really takes place. Technical knowledge is vital, but pilots are not seeing the rest of the world…and they don’t know it. But we’re smart people and we can change. We’re not slaves to the inevitable.”

NATA’s Koranda said, “I don’t think you should ever say a particular accident rate is low enough. You never quit. It is not the same as yesterday or the same as tomorrow. You are never too small to have an accident. You must constantly refine your process. Anyone who thinks otherwise is running on dumb luck and it will catch up with them.”

According to Tom Roberts, the Navy slogan at Pax River is, “Considering accidents a cost of doing business is unacceptable.” New World Jet’s Kunert said, “As time goes by, we as an industry will have to collectively put our heads together with the FAA and ask where the common thread is to pull all of these safety management programs together.”

But change in the industry is slow. Improving business aviation’s safety record will not happen overnight.

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