Air Safety

At a time of rapid expansion in air transport, average pilot experience levels are dropping sharply and many new pilots hired by airlines are not what they should be. But airline marketing still tries to reassure the public about safety – without even mentioning the word – by subtly investing pilots with an air of mystical infallibility. The nervous passenger being herded like a beast for slaughter down a crowded jetway towards the ominous and shrouded final gateway of the aircraft door, may catch a glimpse of the aircraft’s magnificent captain.

If the advertising has done its job, the passenger may feel that his or her fate is in the hand of a major god with four gold rings on his sleeve. But according to speakers at last week’s seminar, too many pilots -and their management- are tending to believe their own publicity and omit to ensue that reality matches the myth.

Capt Heino Caesar, General Manager – Flight Operations Inspection and a pilot with Lufthansa, described current pilot training as “technically overloaded and psychologically not state of the art. ” He claimed pilots have not learned much since the days of the mythical Icarus who made the same basic mistakes we still see today.

“Overconfident in his own abilities, Icarus did not listen to his father and supervisor, Daedalus,” Capt Caesar said. “Careless or ignorant about the limitations of his flying apparatus, he misjudged and underestimated the dangers of the environment and made the fatally wrong operational decision to continue his flight too near to the sun instead of going around and diverting. ”

“He paid with his life for his error and we continue to pay this toll -in most cases unnecessarily. ” Capt Caesar said major factors in many recent accidents included lack of pilot motivation, coupled with excessive confidence, complacency induced by numerous uneventful landings and the ‘follow-my-leader’ syndrome with individual crew members unwilling to speak their mind. Seventy 6% of accidents were caused by human failures of the cockpit crew, compared to only 11% for technical reasons and 13% for environment (mostly weather but also ATC, airports, terrain, navaids, lack of information, support failures and cabin crew. )

Caesar said 25% of all human failures were ‘active failures’ where the crew were aware of what they were doing. These included non adherence to rules and SOPS (standard operating procedures), lack of discipline or vigilance, inadequate flight management and short cuts. A further 20% were passive failures where crew were unaware of what was happening through misunderstanding and communication problems, complacency, forgetfulness, distraction, coordination breakdown, fatigue, boredom and lack of assistance. Fully 50% were proficiency failures or judgement errors including inappropriate handling of aircraft or systems, misjudgment, lack of experience, training or competence. Only 5% were crew incapacitation – the stuff of movie dramas – involving takeover of duties because one flight crew member was unable to perform because of physical or psychological inability.

“While we can fight passive failures with good crew coordination concepts, precise and standardised phraseology and systematic work distribution and are able to train judgement and decision making even in simulators, the amount of active failures is alarming,” Capt Caesar said.

“Lack of discipline, conscious deviation without sound justification from rules and procedures which have been paid for with blood, sweat and tears, is unprofessional for an airline pilot and inexcusable. Nevertheless, this happens due to macho behaviour, frustration, striving for self esteem, over confidence, lack of problem awareness and carelessness.

“Preliminary investigation indicates lack of airmanship was significant in at least two out of three takeoff losses and in five out of six landing losses, in all four approach losses and in one descent loss in 1987. The year was characterised by a number of accidents and incidents which could be attributable to either a lack of training, experience and support or lack of professionalism, commitment and motivation. In the more significant events a mixture of both could be observed -trying to land without gear and flaps, landing without clearance and colliding with a backtracking aircraft, gross errors with near collision and subsequent attempt to conceal the error, omission of vital actions prior to takeoff resulting in a subsequent crash, two pilots with extremely low type experience found at the controls of a crashed DC-9. ” Capt Caesar said there were indications that landing accidents were increasing because pilots often felt obliged to force landings under unfavourable conditions to keep to schedule and to avoid additional costs or working hours, even though the ·skills required might be beyond their capabilities.

A Lufthansa study over a 29 year period showed average operational total losses during various phases of flight as – Takeoff 23%, Climb 7. 3%, Cruise 2. 7%, Descent 8. 4%, Approach 32. 4%, Landing 24. 6%, Ground 1. 6%.

He also said approach losses had dropped from 37. 7% between 1968-77 to 26. 4% from 1978-87 while landing losses had risen from 21% to 33. 3% over the same period.

Capt Caesar said policy factors set out by airline management had to be improved “since undoubtedly in many cases pilots acted under heavy pressure to keep to schedule, land at the destination under all circumstances, not daring to wait until, for example, the weather had improved, or following air traffic control instructions far too slavishly.

“We are loosing nearly half our aircraft in only 2% of the flight time – during takeoff and landing. Crews which operated in a highly disciplined, undisturbed precise way and according to procedures during this relatively short portion of their duty time could eliminate half their theoretical risk” he said. If approach is included, airlines suffer 80% of their losses in 12% of flight time. The reduction in approach losses apparently resulted from better procedures during descent, better altitude awareness by crews, ground proximity warning systems (GPWS), better charts and more high precision approach aids. But the old saying is “good landings follow good approaches” and most landing accidents were caused by excursions – either lateral or overruns – often after unstabilised approaches.

Prime reasons for accidents were poor pilot judgement during approach and final and demonstrated poor pilot technique during landing. “Pilots put themselves in situations which they cannot handle and in which only a timely go-around would have solved the problem,” Capt Caesar said. But there was a long history of pilot reluctance to initiate a go-around which might indicate earlier. errors in judgement or procedure and crews faced their highest workload on go-around – a complex manoeuvre, seldom executed, non-routine and often required or demanded by surprise. Although basic human failure might never be eliminated, reduction of landing accidents required more attention to –

• Encouraging pilots to admit an error and go around when advisable. (refer our Air Safety feature, Jan issue)

• Establishment of precise approach procedures to achieve and strictly adhere to fully stabilised approaches.

• Heightened awareness of the consequences of attempting to land in an unstabilised condition.

• Adequate training for landing under adverse conditions and encouragement to keep up basic skills.

• Education of pilots to improve their judgement and management skills and not to force a landing under doubtful environmental conditions on to a contaminated runway without utmost caution and vigilance.

Capt Caesar said heavy, multi-engine long-range aircraft had a safety record three times worse than short and medium range aircraft – partly because their pilots lacked skills due to the low number of manually flown takeoffs and landings they made in normal operations. “We seem to be harking back to the early years of jet introduction,” he said.

“We have to retrain our crews with the help of advanced simulators to ensure the mastering of basic skills and ability to fly by hand and raw data. “We have to convince them of the hostility of certain environments and encourage them to go-around or divert when handicaps accumulate. ”

In the follow-the-leader syndrome, somebody, not necessarily the most experienced crew member, offered an explanation or suggested a course of action which all the others followed without individual, independent thought. “Nobody wants to ruin the nice buddy-like atmosphere or to criticise a nice guy,” Capt Caesar said.

“The judgement and experience of an older captain is respected and taken for granted – the generation gap makes it difficult for a young copilot to speak up. Bad leadership or missing resource management by the captain may result in an intimidated, discouraged crew and finally the necessary redundancy is lost. We must select self confident people, aggressively safe, able to co-operate, willing and able to think and react independently, despite company hierarchy, generation gap, group loyalty and resistance against the follow-the-leader syndrome.

“Our training is in most cases technically overloaded and psychologically not at the state of the art. We cannot create a new man for the cockpit but we can help our pilots to perform more adequately. An effective breakthrough in safety can only be reached through the man in the cockpit, without whom we cannot do in the foreseeable future.

“The more severe the accident is, the more predominant is the human factor – the failure of the human crew,” Capt Caesar said. Mark Twain described man as “a creature made at the end of the week, when God was tired.

“An effective breakthrough towards a better safety record can best be achieved by concentration on human elements in selection, training and supervision of cockpit crews. Liberalised practices in employment of pilots of no aptitude for commercial operations, of pilots with very low experience in general or on type, or pilots with inappropriate experience, require management to exhibit greater responsibility to ensure crews are adequately trained to both attain and maintain appropriate basic airmanship skills.

“Undoubtedly, pilots worldwide spared us thousands of potential crashes by their instinct, experience, vigilance, foresight and knowledge – but this system means that man is also vulnerable in the most complex way. Mostly our problem in the cockpit does not arise from lack of theoretical knowledge but is psychological. A typical phenomenon in crashes is the collective mistake of a two or three man crew.

“Why should we provide the redundancy system in the form of a second pilot if it does not function when it is desperately needed?”

Captain David Simmon, Director of Flight Safety for United Airlines pointed to several ‘safety inhibitors’ – excessive internal politics, the corporate bean counter and reactive management. “Politics distract from the real task at hand and can paralyse an organisation for months and years on matters concerning safety,” he said. “Over concern about rank, who reports to whom, personal prestige, who is right instead of what is right for the organisation, salary and benefits, appeasing others instead of doing what is right for safety of the operation and personal aggrandisement, are all indicators of trouble ahead,” he said.

Bean counters’ influence had increased dramatically since the onset of deregulation. “Some bean counters look at safety departments as another expense which must be reduced to the lowest possible cost,” he said. “The answer is to learn to play their game. Do not let the bean counters pull you down to the lowest common denominator – rather, find the· airline with the best safety programme and use it to pull yourself up to the highest level of safety. ” Reactive management was the final safety inhibitor. “In the final analysis safety is little more than being pro-active instead of reactive,” Capt Simmon said.

“It is easier to react to a problem than it is to prevent it in the first place. ” He blamed senior executives who delegated safety matters to subordinates rather than thinking, discussing, reviewing and agreeing on solutions. Capt Colin Felton, a domestic airl ine captain, is Vice President (Technical) of the Australian Federation of Air Pilots (AFAP) and Regional Vice President for the South Pacific for the International Federation of Airline Pilots’ Association (IFALPA).

Despite the industrial orientation of these organisations, they play a major role in developing and monitoring safety. He questioned the attitude of airlines which he believes is not as honest as it might be. “A lot of airlines want to imply in their marketing that there is no question of safety being maintained,” he said. “It is easy to get general complacency about safety. ”

Australia has had more than its share of good luck in maintaining a better than average standard of aviation safety, he believes. There have been several close calls – a near collision at Sydney airport and a recent near mid air collision over the Australian Bight, as well as some runway overruns which could easily have been more serious.

“We operate in a fairly benign climate with few storms and no snow – but we have a lot of thunderstorms and landings in crosswind and rain, and a lot of aerodromes are not up to the standard of airports in the US and Europe. ” But he also believes that Australian flight decks are highly disciplined, compared to the comparatively laid back attitude on many American and European flight decks. Felton would like to see more public awareness of safety when the cry goes up for lower fares, more services and more competition. “Everything has a cost – particularly safety, although it is not obvious to the public until it hits you in the face,” he said.

“It concerns me that with economic pressure there is going to be more and more pressure on airlines to cut their costs. They should not be featherbedded but there is an economic base below which some things will have to be sacrificed. ” He pointed to a growing shortage of pilots and engineers which is diluting experience levels and heightening the need for comprehensive training.

Dr John Lauber, a member of the US National Transportation Safety Board (NTSB) said the recent crash in France of the computer-controlled Airbus A320 showed that ”the world’s smartest aeroplane is still just an aircraft and has to be flown by a professional, competent crew. ” He said investigations of several recent major accidents in the US, where the crew attempted to takeoff without correctly set control surfaces, showed a great deal of ‘non-pertinent’ conversation. In one accident there was a lengthy conversation prior to takeoff with a flight attendant “on a wide range of subjects that had nothing to do with flying aircraft,” he said. He warned against a decline in leadership in the cockpit – along with ‘good followership. ‘

A lot of incidents and accidents developed because of a lack of effective leadership by the captain,” he said. Too much psychological training involved “warm and fuzzy comments about interpersonal relations” which tended to view cockpit management as getting people to like each other. ” Lauber said no human performance took place in a vacuum- “a failure does not stop at the cockpit door – it extends all the way to the top corporate officers. ” Airlines with exemplary safety records tended to share certain features – MANAGEMENT emphasis on safety – “the commitment to safety begins at the top. ” A PROACTIVE and visible flight safety organisation with independent line checking separate from training. STANDARDISATION and discipline.

Captain Ken Davenport, Qantas director of flight operations and chief pilot, pointed to swings in community attitudes as one reason for a weakening of traditional cockpit discipline. “In Australia, the human qualities of the youth- ‘our future aviators’ – had changed from one of respect and acceptance of tradition to one of question and non-conformity,” he said. He believes lack of discipline became very evident during the late seventies “when scholastic ambitions underwent great changes. Home discipline was one of self discipline and school discipline was often influenced by a non-conforming, usually long haired, left of centre school teacher,” he said.

“In essence, youth, the base product of our industry, hac undergone changes – so maybe it could be said man has changed, but not necessarily for the good of the air piloting profession or our industry. ” Capt Davenport said flight training also suffered changes with the quality of some instructors “becoming questionable. ”

“The end result was the individual who presented himself and later herself, to the airline recruiting office, was not meeting the airline basic requirements. Lack of motivation was often found, low discipline levels were evident, inability to handle basic instrument flight was proven and little leadership was displayed- too often these characteristics were found in the applicants. ” Psychological tests turned up numerous applicants with low IQs. But Davenport believes the quality of pilot recruits is now improving. “I am confident that new pilots recruited today make up in keenness where they lack in experience,” he said. “New recruits are displaying more dedication and professionalism than their predecessors. ” But he warned that with enormous expansion in the airline industry and shrinking pilot availability, there was a tendency for airlines to lower entrance levels. Selection was limited by supply and demand but where pilots just made the required standard there was no allowance for any reversion to old practices and non-standard procedures.

“Any downward trend in performance will become an unacceptable standard and this standard may cost the company and the industry dearly,” he said. Capt Davenport was not impressed by US deregulation’s effects on pilot quality.

“Many fly by night or mushroom airlines emerged then died,” he said. “The pilot population became very nomadic – just change the name on your uniform and you were back in the air. Standards of some airlines became questionable due to lack of strong operational management and controls. The enormous financial pressures on the operations departments caused training to reduce and the standards to become marginal – many airlines were cutting corners to stay alive.

“Spasmodic pilot selection was often uncoordinated and uncontrolled. ” At much the same time the pilots’ role was changing from ‘controller’ to ‘manager’ as automation reduced manipulation by pilots. Automatic landings superseded manual landings and the pilot now needed skills in inter-human relationships to manage the much larger crew,” Capt Davenport said. “The industry saw automation as the cure to aircraft accidents – but in doing so tended to take the pilot out of the loop. In automated cockpits the pilot must manage what is going on and understand when to take over. Unfortunately the industry again learned the hard way.

“In the cockpit and in the board room everyone was teaching and espousing the wisdom of cockpit resource management. Why? Because the pilot was not necessarily the best manager of resources. Unfortunately, it appears man is lagging behind his machine. Evolutionary changes to man seem to have been minimal whereas advances in the machine are enormous. “