NTSB LOC Forum Spotlights Culture, Training Issues
GA has not seen same safety improvements as commercial airline industry, with LOC the accident statistics, NTSB said.

The aviation industry has come together in a multipronged effort to attack one of general aviation’s most pervasive safety problems: in-flight loss of control (LOC-I).


Statistics point to LOC-I as the leading killer in fixed-wing accidents, dwarfing all the other major categories. From 2008 to 2014, LOC-I played a role in 46.4 percent of all fatal accidents and 45.8 percent of fatalities from fixed-wing aircraft crashes. The overwhelming majority of the LOC-I fatal accidents involved general aviation flights operated under Part 91 for personal reasons. And while flight into poor weather is often thought of as a typical cause, only 12 percent involved instrument meteorological conditions.


The NTSB added prevention of general aviation loss of control in flight to its Most Wanted List of Transportation Safety Improvements this year “in response to some alarming trends in crash statistics,” NTSB member Earl Weener said.


The good news, Weener told AIN, is the level of attention the issue is getting across the industry. The harder part is what to do about it.


Weener recently presided over a day-long forum to delve into human performance, training and equipment factors that either play into or could help prevent LOC-I accidents. The forum drew a cross section of safety specialists from government, academia, manufacturers, flying clubs and general aviation organizations.


The general aviation community, through the General Aviation-Joint Steering Committee (GA-JSC), began to take a data-driven approach to analyzing accidents in 2011, similar to that taken by the Commercial Aviation Safety Team. “But we are at the very beginning of the journey,” said Wendell Griffin, director of the FAA’s Office of Accident Investigation & Prevention and co-chair of the GA-JSC.


Culture Changes


Examining the data, the committee has devised 33 “safety enhancements” that are either now in place or under way to tackle general aviation safety, including LOC-I accidents. Chief among them is the Fly Safe Campaign, a massive community outreach initiative deployed by nearly 2,500 volunteers to disseminate safety messages. He estimated that these efforts have reached 1.6 million people.


GA-JSC participants have looked at safety outreach as the quickest, easiest way to reach the pilot community. While it might rank as low-hanging fruit, it is important as a mechanism to change pilot habits and culture. “At its core, loss of control is a human performance issue,” Weener said. “It takes only one moment of inattention, a miscalculation or a mistake to precipitate a loss of control in flight.”


Participants agreed that the bedrock culture of pilots has to change if the tide of LOC-I accidents is to be turned. “This is our biggest challenge,” said Sean Elliott, vice president of advocacy and safety for the EAA. “The way to change behavior is to change the culture. That is what we have ahead of us,” he said.


In the commercial arena pilots must follow standard operating procedures and a level of requirements set by both their employers and the FAA, but recreational pilots do not have such a formal operating environment and are more focused on the passion and freedom of flight, he said.


A number of researchers have studied the human-factors role involved with use of various technologies in the cockpit and how it could play into accidents such as LOC-I. Frederic Dehais, professor with the Institut Superieur de l’Aeronautique et de l’Espace, cited studies showing that pilots who get aural warnings do exactly the opposite of what they are expected to. “They are supposed to pull on the stick and they push.” Other studies show pilots simply ignoring the warnings.


Colorado State University professor Christopher Wickens said aural warnings can create a “startle” effect, introducing or intensifying stress and impairing decision-making, particularly in the context of LOC-I. He favors a command-based system rather than a simple aural warning.


Training Updates


Panelists at the NTSB forum suggested a fresh approach to training. “Pilot training is stuck in the 1970s,” said George Perry, senior v-p at AOPA and head of the association’s Air Safety Institute, noting a lack of simulator training and absence of attention to angle of attack (AOA) and a stabilized approach in training documents. “A stabilized approach is just as important to a general aviation pilot as it is to a commercial pilot,” Perry said.


The Society of Aviation and Flight Educators (Safe) has launched a “Learn to Turn” initiative because “pilots remain unconsciously incompetent with regard to flight,” said Rich Stowell, a master aerobatic instructor with Safe. “[Pilots] believed their training would teach them how to maneuver an airplane and we failed them. We have a training delivery problem,” Stowell said, noting that LOC-I frequently occurs in maneuvering phases.


In surveys, pilots were asked what happens while an airplane turns. One-quarter answered that the rudder makes the airplane turn, even though core pilot training publications make it clear that the rudder does not turn the airplane. “It’s no wonder that loss of control while maneuvering is the top reason for fatal accidents. The pilot is miscommunicating with the airplane,” Stowell said.


Stasi Poulos, president of simulation and training specialist Mindstar Aviation, noted that the company established a simulation experience to show pilots how to recognize the potential for LOC-I in an inadvertent transition from VMC into IMC. “We found that 80 percent of the pilots failed to turn around early in the flight even as conditions deteriorated. Fewer than 30 percent called for help on the radio,” he said.


Pilots have shown reluctance to use the radio, and many are not prepared for secondary failure, he said. “We should be getting people to recognize these problems in simulators long before they get into the real airplane,” Poulos said.


The FAA and industry have been drafting new airman certification standards to reflect the evolving environment, said David Oord, vice president of regulatory affairs for AOPA. Those standards are currently being prototyped, and officials hope to release them next year.


Embrace Technology


While the FAA collaborates with industry on cultural and training changes, Weener sees technology improvements as “the most desired” approach to solving loss of control. Pointing to other technological successes such as ground proximity warning systems, he said, “If you can solve the issue with technology, then you don’t have to change behavior.”


The ASTM F44 international standards committee is turning its attention to follow-on technologies for stall warning, now that the FAA has paved the way for easier installation of AOA indicators. ASTM F44 member Jeffrey Pierson said the committee is looking at “version two,” which might include some tactile warning for stall warning. The committee is exploring concepts such as low-cost vibration technologies that could either augment an AOA or be incorporated as a multi-mode stall warning system.


As for the AOA indications, attendees at the forum discussed a need to standardize the displays. Dennis Berringer, senior scientist for flight-crew performance research in the FAA’s CAMI Human Factors Laboratory, noted a lack of specific display standards for AOAs in the aftermarket. “We need to put into place display standards for these things to make sure they are effective across the board,” he said, noting that pilots should know how to calibrate and effectively use them. Steve Jacobson, senior v-p for product development at Avidyne, said he could see avionics manufacturers making AOAs standard equipment in their avionics suites in the future.


While AOPA’s Perry agrees that technological solutions are important in addressing LOC-I, he emphasizes that they must be simple, affordable and clearly worth having on board.