Bombardier Safety Standdown
“We do many things for the industry throughout the year, but this is the one that makes me the most proud,” said James Hoblyn, v-p of Bombardier’s business aircraft division, during his opening remarks at the 2005 Safety Standdown held recently in Wichita. This year marked the Standdown’s ninth year, and the sixth year since it was opened to corporate pilots outside of Bombardier. “Safety Standdown continues to grow in size and reputation. It reflects the collective commitment of the people in this room to redefining and pioneering human-centered training for the aviation industry.”
According to Hoblyn, Bombardier hosted 435 attendees at its 2005 Safety Standdown, the largest audience yet, and still had to turn away more than 150 others who had wanted to attend the free training. Approximately 60 percent of this year’s attendees were first-timers, and nearly half of all attendees did not fly Bombardier products. Although virtually all in the room were pilots, aircraft flown ranged from pistons to Boeing Business Jets. Attendees represented 232 organizations, including 58 Fortune 500 companies and nine government agencies.
FAA associate administrator for aviation safety Nicholas Sabatini opened the first session by praising Bombardier for its efforts to bring human-centered training to corporate aviation.
“The weak link in the fuselage is wearing a headset,” said Sabatini. “Even as we look to technology to provide the answers [to aviation safety], we recognize that the toughest issue to resolve is the human component.”
Sabatini noted the FAA is working with industry groups to establish new FAA Industry Training Standards involving scenario-based training and innovative instruction methods.
“As the airspace grows in depth and complexity, we must focus resolutely on increasing the margin of safety for general aviation,” Sabatini said. He listed three ways to raise general aviation’s margin of safety: increased use of technology, cooperation between government and industry watch groups and fostering a culture of safety within organizations.
Sabatini cited NetJets as an organization with an excellent safety culture as indicated by the crewmembers’ empowerment to say “no” to a flight without fear of personal retribution. “Crews know they have the personal backing of the company to give them confidence to say no, and they have a system in place to support the practice,” Sabatini said.
He told a story of a NetJets fractional owner who insisted that the aircraft depart and proceed to the destination, even after the flight crew explained it was not safe. “The customer proceeded to call [NetJets chairman] Richard Santulli,” Sabatini said. “After talking to the pilot, Santulli told the customer, ‘Not only will you not go, you will find your share of the aircraft ownership on your desk when you return to the office.’”
Sabatini said that although a culture of safety must start with individual pilots, they need to have organizational support.
War on Error
This year’s Safety Standdown theme, “War on Error,” set the tone for many of the human-centered training presentations during the two-day event. Dr. Tony Kern, a former Air Force Academy instructor and flight examiner in the B-1B bomber, kicked off the first training session with a presentation on this theme. A leading authority on human performance in aviation, having written five books on the subject, Kern currently serves as senior partner at Convergent Knowledge Solutions, a firm dedicated to “reducing human error in high-risk environments.”
“In spite of multiple serious efforts to reduce human error, the number of errors remains relatively constant,” Kern said, indicating that the traditional method of studying mishaps and focusing on one cause to prevent that mishap from occurring may be at fault. “When we focus on one area, we might reduce errors in that area a bit, but other contributing factors tend to go up.”
One reason human error continues to be a leading cause of aircraft incidents is because pilots don’t understand why they make errors or how to prevent them. Instead, they rely on technology, systems, cockpit resource management and their training to trap and resolve errors.
Kern’s solution is to incorporate cognitive training early in the flight training process. In addition to learning systems, procedures and tactics, student pilots would also be taught why they make certain errors and how to prevent those errors from occurring.
Not counting the cognitive training that few pilots receive (except perhaps at Safety Standdown), Kern emphasized flight discipline–doing the right thing despite the temptation to do otherwise–as the most potent personal error-reduction tool. This means flying within the layers of protection established by various entities in the air transportation system, including government regulations, the OEM’s aircraft flight manual, the corporate flight department’s standard operating procedures and safety management system, and the pilot’s personal minimums.
“Errors are not caused by breaking through layers of protection, but when the pilot flies outside the layers of protection,” Kern said. “Flight discipline is the anchor. If it breaks down, you can no longer assume that any other rule or procedure will be followed.”
Kern indicated four types of non-compliance stemming from lack of flight discipline: routine, such as continually shorting crew rest; optimizing–creating work-arounds or streamlining procedures; situational, usually a result of poor planning that requires things to be done outside the rules “just this once”; and rogue violations. Although all of these can lead to human error, the rogue violation can be the most serious because it’s an ego-driven error that usually results in progressive deviations.
Since pilots are necessarily mission-driven people, they can be more easily tempted to bend or break rules to accomplish the mission. To emphasize his point, Kern polled the audience as to their opinion on the following statement: The minimum equipment list is a good guide but can be tempered with pilot judgment on low-risk, high-reward missions.
Recording their responses anonymously through wireless electronic polling devices set in front of all 430 plus participants, more than 30 percent of the standdown pilots agreed with this statement. On a follow-up question, 28 percent admitted that they have had to “push weather or fuel minimums to accomplish a mission.”
Increasing Professionalism through Discipline and Training
Former Apollo astronaut and current Learjet 45 pilot Capt. Gene Cernan also emphasized the need for discipline among pilots during his presentation on professionalism.
“Anyone can become a professional by name,” said Cernan. “But professionalism in aviation takes on a higher level because of the added fourth dimension of time.” Unlike many other professions in which the operator can call a “time out” to think about various options, pilots operate in an environment that’s getting even more time-critical as technology pushes past traditional boundaries. For example, Cernan likened flying below 200 feet to the challenge of going to the moon, both in terms of technology leaps and the effects on the pilots’ psyche.
“The loss of an engine at 200 feet on a foggy night is not much different from losing a thruster while landing on the moon,” Cernan said. “In either case, you’ve got less than 30 seconds to make decisions.” In this time-critical environment, Cernan said, applying skills and knowledge with courage and discipline is an absolute requirement that in turn fosters professionalism in the cockpit.
“Professionalism is an outgrowth of commitment, knowledge, discipline, courage and passion for aviation…Professionalism in our profession requires a commitment to be the best. If you’re not committed to being the best, then perhaps you’re in the wrong profession because anything less is absolutely unacceptable.”
Although training is essential to increasing knowledge and applicable skills, Cernan said the professional aviator needs to look beyond traditional simulator training to excel. “Simulators are great training tools,” he said. “But the student can still call a time-out in the simulator. You can’t do that in the real world. Don’t be satisfied with being in a simulator. Take yourself as close as possible to the real world.”
Cernan described the lunar landing training vehicle (LLTV) that he and other Apollo astronauts used when learning how to land the lunar module on the moon. Equipped with four rocket pods, one at each corner, the LLTV was “totally unstable and totally non-aerodynamic” and had six degrees of freedom. Cernan said it provided as close to a real-world simulation as possible, especially since “the surface of the earth is as hard as the surface of the moon if we made a mistake.”
Cernan recommended upset training as a pilots’ best real-world emergency training.
Cernan’s upset training recommendation echoed a comment made earlier in the day by Bombardier director of flight operations and test pilot Bob Agostino, one of the principal driving forces behind Safety Standdown.
While presenting a brief synopsis of safety issues faced by the corporate aviation industry, Agostino reported that from 1994 to 2003, some 32 airline accidents worldwide have been attributed to aircraft upset, resulting in 2,100 fatalities, and in the past 14 years there have been 585 loss-of-control events worldwide in corporate aircraft.
Dr. Mark Rosekind, president and chief scientist of Alertness Solutions, has been a regular speaker at the standdown for several years, not only because fatigue is a serious safety issue but also because it continues to be prevalent in corporate aviation. Rosekind shared statistics compiled from a NASA survey of nearly 1,500 corporate pilots that showed 61 percent of the surveyed pilots reported fatigue as “common” in flight operations, 71 percent admitted to having “nodded off” in the cockpit and 13 percent reported fatigue had prevented them from flying a trip. Yet only 21 percent reported having any type of fatigue training offered.
Developing Good Sleep Habits
“Fatigue extracts high costs,” said Rosekind. “When you lose sleep or disrupt your sleep clock, every aspect of your capability as a human being is impaired.” According to Rosekind, even moderate sleep loss can result in decreases in memory (up to 20 percent), vigilance (75 percent), communication skills (30 percent), reaction time (25 percent) and judgment-making skills (50 percent).
Flight schedules often force pilots to attempt sleep when their Circadian rhythms prefer their bodies to be awake, and vice versa. Rosekind warned pilots not to use alcohol as a sleep aid. Although alcohol is a relaxant and can help a person nod off, it suppresses REM sleep and disturbs sleep in the second half of the night.
Acute sleep loss can also mimic the effects of alcohol on pilot performance. Pilots who have been awake for 16 hours can have a blood alcohol content (BAC) equivalent of .05 percent; 24 hours without sleep mimics a BAC of .10 percent. Add just a little sleep loss to a few alcoholic drinks, and the effects of the alcohol worsen. Just two drinks and two hours of lost sleep can add up to an equivalent BAC of .045 percent.
Sleep habits change as a natural course of aging. People over the age of 50 tend to wake up more at night and can’t get into deep sleep, depriving the brain of its normal eight hours of required sleep.
Rosekind did offer solutions for battling fatigue, including proper use of caffeine. He said that caffeine can take 15 to 30 minutes to work, but the effects can last for three to four hours. Between 100 and 200 mg of caffeine are needed to have any effect; typically 115 to 175 mg are in a normal cup of coffee, but a can of soda contains only 55 mg or less. Caffeine can also be addictive, and its effectiveness decreases with heat.
Since getting enough sleep is the best offense against fatigue, Rosekind recommended that pilots take advantage of napping opportunities whenever possible. Often 10 to 20 minutes is enough to refresh the brain, but Rosekind cautioned against longer naps unless a full two hours can be spent sleeping to allow the brain to process through the entire REM/non-REM sleep cycle. After a long nap, allow approximately 15 minutes to “wake up.”
Good sleep habits can help coax the body into sleep. Getting regular exercise during the day can help the brain rest at night. Also, use a regular pre-sleep routine to condition the body that it’s time to sleep. Avoid work and worry in the bedroom; the body should equate the bedroom with a place for relaxation, not work.
If needed, eat a light snack before bedtime to avoid going to bed hungry. Don’t toss and turn for more than 30 minutes. Get out of bed and do something relaxing until you feel sleepy.
Taking melatonin, a natural hormone that helps to induce sleep, is also an option. However, Rosekind cautions that since melatonin is not regulated by the Food & Drug Administration, there’s no guarantee that pills purchased at the local health food store actually contain enough of the hormone to induce sleep. He says researchers have analyzed melatonin pills purchased at random and found concentrations between zero and 100 percent in different pills.
Safety and Your Health
Aviation medical examiner Dr. Lawrence Lay also discussed the human body’s need for sleep during his talk on “Safety and Your Health.” A former engineering test pilot for Beechcraft and a family practice physician for more than 26 years, Lay reminded pilots that sleeping pills are “inappropriate” for people who fly.
Like Rosekind, Lay recommended pilots use melatonin to fall asleep, although he stipulated a limit of two doses per week and also cautioned to be careful of the pills’ source. Lay’s main sleep-related points focused on sleep apnea, which occurs in approximately 2 to 4 percent of the U.S. population according to figures from the American Lung Association.
Sleep apnea occurs when breathing ceases during sleep due to repetitive closure of an airway; the sleeper continually wakes up to begin breathing again, resulting in severe loss of sleep at night and an overwhelming urge to fall asleep during the day. According to Lay, sleep apnea is a medically disqualifying condition that requires treatment.
As sleep apnea is most prevalent in overweight males, Lay advises a healthy lifestyle of proper diet and exercise to avoid developing this and other health issues, including diabetes and unconscious episodes due to low blood sugar. He says pilots can be susceptible to low blood sugar due to their demanding schedules, which often prevent them from eating regular and healthy meals.
As an example, he cited one of his patients who became dizzy and unresponsive in the cockpit after drinking cranberry juice on an empty stomach. When the high-sugar-level juice hit his system, his pancreas went into overdrive, removing the sugar from his blood to produce insulin, resulting in a low blood-sugar condition.
“He didn’t do anything different from what everyone in this room has done at one time or another,” Lay said. “We don’t get a good night’s sleep. We run to the airport the next morning, generally drink too much coffee on the way and haven’t eaten properly. We get to the airport and have something that’s a high sugar load, like an orange, and boom, we go to altitude and we’re unconscious.”
Lay says that he had two of these cases as an AME in the past year alone and wonders how many accidents are actually attributable to pilots passing out in the cockpit from low blood sugar. Because of the obvious safety issue, getting medically recertified after a pilot has had an unconscious episode can be difficult, especially if it’s not clear what caused the brain to shut down.
Pilots with diabetes can obtain special issuance medical certificates if the disease is controlled through medication or insulin. According to Lay, proper diet and exercise can help control blood sugar levels and prevent the onset of Type II diabetes.
Alcohol temperance, limiting drinks to no more than four ounces per week, will also help maintain an even blood sugar level as well as prevent alcoholism and other diseases associated with drinking.
Citing pilots’ prevalent use of alcohol as a relaxant and noting that the FAA will revoke a pilot’s medical certificate after two convictions for driving under the influence, Lay recommended pilots quit drinking alcohol at least 72 hours before flying. “Alcohol goes away rapidly,” Lay said. “Your blood alcohol level can go to zero rapidly, but the effects of alcohol are still there…It takes about 14 hours for the effects of two beers to go away.”
Since alcohol also increases blood pressure, Lay advised pilots with hypertension (high blood pressure) to be extremely careful with their drinking habits. A risk factor for stroke and heart disease, hypertension is “so common now that as an AME, the FAA authorizes me to issue a certificate on blood pressure medicine without calling them,” according to Lay.
The AME has little influence over the FAA’s decision on whether or not to grant a special issuance for heart conditions, however. Whenever a pilot receives a stent, angioplasty or other heart-related operation, the FAA requires a mandatory six-month waiting period after the operation before its independent cardiology review board, which reviews each application on a case-by-case basis, will even consider the special issuance application.
Once the six months pass, the AME must submit original electrocardiogram/exercise stress test and/or angiogram results to the FAA’s review board at Oklahoma City. Lay says the FAA will usually return the results in three to six weeks, although it is currently about three months behind. A favorable result will grant the medical certificate for a maximum of one year, at which time the tests will need to be rerun to ensure the heart’s condition has not worsened.
Applied Aviation Psychology
For Dr. Jerome Berlin, former instructor pilot for the Israeli Air Force and director of Embry-Riddle Aeronautical University’s Aviation Research Center, getting pilots in tune with their inner feelings is difficult but necessary to improve pilot performance.
“One thing that separates professional pilots from the rest of society is that pilots tend to be feeling-deprived,” Berlin said. “We don’t have the feeling structure that other human beings do, and that’s not an accident. In the pilot selection process, we select people like that, especially in the military but in the airlines, too…When the number-one engine fire light comes on at 35,000 feet, the captain [can’t] turn to the copilot and say, ‘George, I’m kind of scared.’”
Berlin showed a pressure/performance curve that depicts performance as a function of stress or pressure. “The more pressure you put on a pilot, the better he performs, to a certain point. Pilots can go higher (more pressure) on this scale than the normal human being.”
Berlin cited an application of the pressure/performance curve used while he served as chief of training research and development for the Israeli Air Force. He said that while the training department kept combat pilots lower on the stress scale during training, they could go two to three years without training fatalities.
But when those pilots were sent into actual combat, they took “unacceptable losses.” When the department ramped up the stress levels during training, they incurred at least one training fatality every year, but in actual combat the pilots suffered almost no losses.
According to Berlin, pilots are good at sliding up and down the pressure/performance scale. They can go up the scale in milliseconds, but it takes quite a while to come back down.
While performance increases as a function of pressure, the pilot’s interpersonal skills decrease. This is one reason relationships often suffer among pilots and their spouses. When the pilot comes home from a flight, he may still be up on the pressure/performance curve, which means his interpersonal skills may be low or non-existent.
Another trait that can affect interpersonal skills both in and out of the cockpit is a pilot’s compulsive tendencies. “There’s nothing that satisfies a pilot’s mind and body like doing a checklist,” Berlin said. “We get very satisfied by doing things in order.” While Berlin says it’s that very compulsivity that makes a good pilot, some pilots extend their compulsion to their outside lives, projecting their need to be compulsive onto their families and other people.
The compulsivity inherent in pilots can present some serious cockpit resource management problems, especially when one pilot is less assertive than the other. Because pilots tend to stay focused, it’s hard to turn their attention to something else, even when it’s a copilot trying to indicate a safety-related concern. Since it’s hard for pilots to express a feeling like “I’m uncomfortable with this approach,” most pilots will point something out only once, if at all.
“One-third of subordinates who see something wrong in the cockpit cannot bring themselves to do the mutinous act [of either saying something or taking control],” Berlin said. “We don’t want the subordinate crew to get cocky, but there are times that they have to take over the airplane for safety’s sake.”
Facts Emergency Training
Although the standdown officially runs for only two days, participants could elect to attend two optional days of specific training. These all-day optional training sessions included the psychology workshop for managers, international operations recurrent training and Facts emergency training.
Facts Training International presented its one-day intensive emergency procedures training course on two consecutive days to enable the maximum number of participants to attend. As it has at previous years’ standdowns, Facts presented hands-on training in CPR and defibrillator use, land evacuation using a full-motion cabin evacuation simulator and water evacuation using Winslow life rafts and the infamous “dunkers.”
This year, however, Facts added two new items to its standdown training: hypoxia awareness using a reduced oxygen breathing device (ROBD), and fire suppression using a portable extinguisher trainer device.
“It doesn’t get much worse than an airplane on fire at altitude,” said Facts instructor Brian Hayvaz. “Under the right conditions, a fire can double in size every 20 to 30 seconds. You must be aggressive when it comes to aviation firefighting.”
Lavatories, trash receptacles, wire bundles and electrical equipment racks can all be sources of in-flight cabin fires. DVD players installed within cabinetry can overheat and start fires if the unit’s temperature sensor fails.
Fortunately, said Hayvaz, most corporate aircraft are equipped with the best weapon to fight nearly any type of fire– halon, which attaches itself to oxygen particles and deprives the fire of the oxygen needed for combustion. He said that fears of causing harm to passengers by using halon in an enclosed environment such as an aircraft cabin are unfounded.
“Halon can be considered toxic in certain amounts, but not in the bottles you have [on board aircraft], and not [being] sprayed into the air,” Hayvaz told standdown participants.
Unfortunately, environmental concerns stopped halon production in the early 1990s, making the remaining halon stores more expensive and harder to obtain. Hayvaz urged corporate flight departments to keep the halon fire extinguishers on aircraft despite the expense, because of the rapidity with which halon can put out fires.
He showed video of trainees attempting to put out fires with different types of extinguisher; the halon extinguisher put out fires that dry chemical and carbon dioxide (CO2) extinguishers could not, but it did so within a few seconds of coming into contact with the fire.
Hayvaz also said that while backdraft–a fiery explosion that occurs when a blast of oxygen hits smoldering material–cannot happen in an aircraft because of the volume of air movement through the cabin and cargo area ventilation systems, flashover fires can and do happen. A flashover occurs when the gases from combustion are themselves flammable. These gases can fill the cabin and instantaneously ignite, offering no hope for any people inside.
Hayvaz illustrated this point by showing video of an Air Canada DC-9-32 on the ground and in flames. During the flight, the cabin crew tried to use a CO2 extinguisher to suppress a hidden fire indicated only by smoke in the lavatory. The DC-9 made an emergency landing only 17 minutes after the smoke was discovered, but a flashover occurred during the evacuation process, killing 23 of the 41 passengers.
After the in-flight cabin fire briefing, Facts participants had an opportunity to extinguish a live fire generated by the propane-fueled portable extinguisher trainer. Hayvaz demonstrated the proper way to use the extinguisher, holding the bottle upright, aiming at the base of the fire and using a side-to-side sweeping motion to extinguish the fire.
After battling fires by depriving them of oxygen, Facts participants themselves experienced what it feels like to be deprived of oxygen through the hypoxia awareness training. Providing a variable amount of oxygen and nitrogen through a facemask, the Facts ROBD can simulate altitudes up to 30,000 feet.
Crewmembers on the ROBD training device generally feel hypoxic effects–which can include tingling in the fingers, blurring vision, headache and tunnel vision–within four to five minutes, depending on that person’s physical condition and the altitude simulated. Facts personnel monitored participants’ heart rate and oxygen blood saturation levels and tested for reduced visual capabilities, degraded motor functions and cognitive abilities while on the device.
While only the approximately 150 Facts participants had the opportunity to actually experience hypoxia using the ROBD, U.S. Navy Captain Donna Murdoch used a similar device during a hypoxia awareness demonstration for all 435 standdown participants. Built by Environics, the Navy’s ROBD2 can simulate altitudes up to 40,000 feet and climb rates from one foot per second to 1,000 feet per second.
Murdoch selected two standdown pilots to participate in the demonstration, which entailed flying a PC-based simulator on stage while hooked to the ROBD2 via an oxygen mask. A Navy corpsman provided ATC simulation; the verbal exchange as well as the video of the participants’ flight simulator panel and vital statistics such as heart beat and blood oxygen saturation level (in percentage) monitored by the ROBD machine were broadcast to the watching standdown audience. Flights began at a simulated 10,000 feet, and then climbed to 25,000 feet after approximately three minutes.
“What you’ll see is that [the participant] will stay [at a blood oxygen saturation level] in the high 80s, then there will be a sudden dip,” Murdoch said. “Hypoxia doesn’t occur gradually. There’s a sudden drop-off, and that’s when you’ll feel the effects.”
The first participant, Jeff Truhan, asked to be put on 100-percent oxygen when his blood saturation level reached 65 percent, but only after he missed several “radio calls” and had to be coached at times by ATC and Murdoch to call for oxygen.
“Tingling of the fingers came on fairly quickly,” Truhan said during the hypoxia demonstration debrief. “It got more and more difficult to concentrate. Also, the colors (on the simulator screen) became more gray or even black and white.”
Murdoch said each person experiences hypoxic effects differently. For the second hypoxia participant, Fred George, the effects of aging factored into the equation. While Truhan stayed at 25,000 feet for several minutes before going back to 100-percent oxygen, George found himself asking for the oxygen within seconds of hitting 25,000 feet.
“When you pass 50, it makes a huge difference on what happens when you start losing oxygen,” George said. “I thought I had my cognitive skills but I started to feel uncomfortable: labored breathing, hot flashes, a little bit of tingles [in the fingers] and so forth. I could sense there was something really wrong.”