Bombardier Safety Standdown 2006
Traditionally, the term “safety standdown” refers to a temporary halt to military operations following a string of accidents. It is an opportunity to stop the frenetic pace of normal operations, take stock of what is and isn’t being done correctly and approach renewed operations with a greater degree of care and preparedness.
Bombardier has run its own Safety Standdown since 1996, when the event was available to the company’s Learjet flight demonstration team. Since then, the Standdown has expanded from internal Learjet pilots to Bombardier customers and, in recent years, pilots, operators and maintainers from commercial, military and corporate aviation.
More than 460 people attended October’s Safety Standdown 2006, the Global War on Error, but many had to be turned away as 930 signed up and there wouldn’t have been enough room at the venue. NBAA joined Bombardier for the first time this year as a major financial sponsor and helped pay to put the Safety Standdown online during the event so anyone interested could view the proceedings.
“Safety Standdown is not saying the sky is falling,” said Bob Agostino, director of flight operations for Bombardier Business Aircraft and the creator of the company’s Standdown. “The information presented here is too important not to share. No one is trying to tell you anything; we ask only that you consider it.”
Added James Hoblyn, senior vice president of customer experience, “This is our way of giving something back to the aviation community.” Hoblyn told the Standdown audience the event is well worthwhile and that “I commit to another 10 years.”
Corporate aviation has had an excellent safety record this year, said FAA associate administrator for aviation safety Nick Sabatini. “Congratulations! The challenge is how to keep up that work. This is a war that never ends.” Sabatini told the audience that the next step is more widespread implementation of safety-management systems (SMS), “to identify and manage risk. If your organization does not have an SMS, this should be the one thing that you take back from the Safety Standdown.”
Training for Emergencies
I observed the high-altitude physiology workshop offered by Human Systems Solutions and participated in the water-evacuation training conducted by Facts Training International. Workshops were held the day before the start of the normal two-day Standdown sessions. Those interested in the psychology workshop for managers (which was closed to members of the press) had to arrive two days early.
Donna Murdoch, COO of Human Systems Solutions, is a retired Navy captain and Ph.D. To simulate the effects of lack of oxygen, Murdoch hooks pilots up to an Environics ROBD 2 (reduced oxygen breathing device), which turns pilots hypoxic without having to depressurize them in an altitude chamber.
To help students recognize their own hypoxia symptoms, Murdoch had them fly the Learjet 45 on a Microsoft Flight Simulator setup while breathing through a mask hooked to the ROBD 2. Acting as an air traffic controller, Murdoch initially gave simple instructions such as climbs and heading changes. The ROBD 2 slowly added nitrogen to the breathing air to simulate a climb to 25,000 feet. The more nitrogen in the air, the lower the percentage of oxygen.
At a simulated 25,000 feet, Murdoch started giving the pilots three tasks at once, such as a heading, altitude and frequency change. At the beginning of the class, Murdoch said, “I will guarantee today none of you will go three minutes [at 25,000 feet].”
Brandon Lundy, a flight instructor at Kansas State University in Salina, Kan., has been in an altitude chamber and never noticed overt symptoms of hypoxia. During the ROBD 2 training, he seemed to perform well even as his oxygen saturation dropped below 70 percent. Murdoch asked Lundy if he was feeling any symptoms, and he said he wasn’t, but his breathing was getting heavy.
At 63-percent oxygen saturation, Murdoch hit a switch on the ROBD 2 to deliver 100 percent oxygen to Lundy’s mask, then asked him to perform whatever emergency procedure he would use in a depressurization.
Lundy reported tingling in his hands and face and said he was becoming fixated on his tasks. “You think you’re feeling fine, but you’re not,” he said after the session.
Rockwell Collins pilot John Kelchen said he felt shortness of breath at the simulated 25,000 feet. He asked Murdoch to switch on the oxygen and quickly began an emergency descent. “Good,” said Murdoch. “You got it right at the beginning, which is what you need to do.”
Murdoch warned the class about a phenomenon that can be confusing. When a pilot first dons an oxygen mask, the added oxygen can initially make him feel worse because of a sudden decrease in blood pressure due to momentary dilation of capillaries. “Do not take your mask off,” she said. “Trust your oxygen system.”
Of course, this depends entirely on there being a working oxygen system, and she urged pilots to preflight the system before takeoff. “When you suspect a problem, put on the mask first.” If you try to troubleshoot the problem first, then it may be too late because one of hypoxia’s insidious symptoms is loss of judgment.
Facts Training International brought two underwater egress dunkers to Wichita. The class split into two teams, one to train in the dunkers and the other in the training life raft. The dunker offers pilots a way to simulate a ditching in which the cockpit sinks upside down. A relatively warm hotel swimming pool is not freezing, roiling stormy water, but the idea is to train for the unexpected so that at least some of what happens is familiar.
Facts instructors Dick Garret, Art Doughty and Scott Arnold carefully explained the procedures that we would use during the dunking exercise, how to strap into the dunker seat, the importance of counting to eight while upside down before trying to exit, how to release the seatbelt with one hand while placing the other hand on the exit area and how to exit the upside-down dunker. We did the exercise twice, once without goggles and once wearing blacked-out goggles to simulate darkness.
When I got in the dunker, the instructor made sure my seatbelt was secure then pulled the dunker frame to release the center portion holding the seat and allowed it to rotate 180 degrees, plunging me quickly underwater. I did the prescribed eight-count, reached for the seatbelt with one hand and the window with the other, released the seatbelt, then followed my window hand out.
The dunking was fun, and while we all knew that it was far from a real ditching, the training accomplished the purpose of providing a simple, repeatable procedure to follow in case of a survivable water accident.
The life raft training was equally useful, mainly because most pilots will never get to use the raft and probably aren’t familiar with how it and all the included safety equipment works. Winslow LifeRaft has worked with Facts for the past seven years and provides equipment for the training programs.
Winslow tech rep David Williams explained the location and use of all onboard equipment and procedures for deploying and entering the raft, then let us climb into the raft while wearing inflated life vests.
Keeping Standards High
Tony Kern, senior partner with Convergent Knowledge Solutions, announced that his company is launching a pilot reliability certification course in January to “standardize and create a known competence culture.” The goal of the program is to “reduce the industry mishap rate by 50 percent, without negatively impacting operational effectiveness or profit- making capability.”
Strategically, he said, “the intent is to dramatically reduce human error.” Pilots who receive credentials from the certification course should enjoy lower insurance rates and be more attractive to companies seeking people with their skills. The curriculum will cover aviation ethics, flight discipline, fundamentals of personal error prevention, crew/cockpit resource management, operational risk management and airmanship.
More important than basic stick-and-rudder skill, Kern explained, is the ability to grow and learn. One method is what Kern calls personal error prevention, using an error-tracking log to figure out why errors happened and how to prevent them using standard operating procedures. “Think of a mistake that you made,” he said, “and write it down, then build personal SOPs [standard operating procedures] to prevent those errors.” This approach fits into the FAA’s current safety philosophy, acting as what Kern calls a “force-multiplier to the emerging safety management system focus.”
Kern used an electronic survey device with a numeric keypad that each attendee could use to respond to instant survey questions to test the audience’s tolerance for bending rules, something that he believes is a major factor in accidents.
In one question, Kern asked if it was permissible to temper an MEL situation to complete a mission. Surprisingly, 23 percent of the audience agreed and 3 percent strongly agreed. A larger number, 87 percent, responded that they have not recently flown below weather minimums or landed with less than minimum fuel.
“If you do only one thing,” Kern said, “restore the integrity of your policies
Mark Rosekind, president and chief scientist of Alertness Solutions, is a regular at safety seminars and has studied sleep and alertness issues for many years, helping the aviation industry understand the effects of sleep deprivation and multiple time-zone travel. “Disrupt your clock and you will pay for it,” he said.
In his studies, Rosekind has tried to assess how fatigue relates to accidents. “Fall-asleep accidents are pretty rare,” he noted. A more likely factor in accidents is sleep-debt. “If you don’t get the sleep you need, whatever you lose builds a debt.” And the debt is cumulative, adding up night after sleepless night. The greater the debt, the greater the chance of reduced performance.
Sleep-debt can’t be overcome by simply “bulling” through important stay-awake periods, he emphasized. Rosekind did say that pilots can split their major daily sleep period into two chunks if needed, without a large effect on performance. If an eight-hour sleep is normal, then splitting that to six hours then two hours should work fine.
Forcing oneself to stay awake can work for only a short period of time, up to 10 minutes. When the body needs sleep, Rosekind said, “You can’t force yourself to stay awake even for life. Your brain can shut you down.”
What works? “Planned naps are the one thing that addresses the physiological need,” he said. The healthiest solution is regular sleep and wake times and a regular pre-sleep routine.
“Speed is life,” said Sean Roberts, test pilot and founder of the National Test Pilot School in Mojave, Calif. Roberts was discussing the Oct. 14, 2004, Pinnacle Airlines Canadair CRJ accident near Jefferson City, Mo., where the engines lost power as the pilots tried to climb the jet too high. According to the NTSB, “The flight data recorder (FDR) data indicate that while the airplane was at 41,000 feet, the stick shaker and stick pusher activated several times before the airplane entered an aerodynamic stall. Almost simultaneously, both engines shut down.”
At that altitude, Roberts said, thrust available is lower than the thrust required to remain at 41,000 feet. “They’re not going fast enough. The most important thing is to lower the nose. It’s better to lose 1,000 feet and notify ATC.”
Roberts explained that typical FAA-sanctioned stall training techniques are not helpful in this kind of situation. The FAA recommends using full thrust and maintaining altitude. “That is a great technique for stalling where altitude is critical,” he said. “But it’s absolutely useless at high altitude with low thrust.”
Roberts offered a useful technique to help pilots memorize the feel of pulling two gs, a number that should be the upper limit for recovering from an upset situation. “To help get to that limit,” he said, “go to a 60-degree bank and remember that force. Then if you ever get an upset, you have a feel for what you can pull to get out of a steep nose-down attitude.”
The Nov. 12, 2001, crash of American Airlines Flight 587 in Belle Harbor, N.Y., has puzzled pilots who have been taught that large control deflections couldn’t harm the airframe if done at less than maneuvering speed.
Roberts helped explain why the vertical fin broke off the doomed Airbus A300, noting that the load on the fin increases with every full rudder reversal. “You can go full rudder one time,” he said. Unfortunately, for whatever reason, the A300’s rudder moved back and forth multiple times and the load on the fin became too high for the structure to bear.
Roberts conducted tests on this phenomenon at the National Test Pilot School, and the results were so dramatic that engineers reading the telemetry data told the pilot to stop the test immediately after one full rudder deflection.
Another area of concern is flutter, which can happen to an airplane flying too fast. The only solution is “Don’t panic. Well, panic. But do it slowly. You can fly an aircraft beyond the flutter limits and recover. The last thing you want to do is jerk the controls. Panic slowly and smoothly. Don’t extend speed brakes.”
Roberts concluded, “Hopefully you never have to see the edge of [the envelope], but if you do, use it to fly home safely.”