January - February 2007
Any Accident Is Everyone’s Accident
Assessing & Managing Risks
Create A Safety Culture
Reduce Aircraft Insurance Costs Through Safety
The TFO Role in Flight Safety
Threat & Error Management: You Can’t Prevent What You Can’t Predict!
So, Who Does Train the Trainer?
The International Helicopter Safety Team’s slogan is...
Any Accident Is Everyone’s Accident
By Matthew S. Zuccaro
President – Helicopter Association International
Let’s talk about safety. However, before I do that, I want to express my sincere appreciation to APSA and Air Beat magazine for allowing me this opportunity to speak about my favorite subject, which I know is a prime priority for APSA members as well.
I am well aware of the various missions performed by APSA members, under demanding conditions, sometimes in unforgiving operating environments. This creates a need for constant vigilance and attention to details. Although we are aware of the need for safety, we unfortunately continue to have accidents at an unacceptable level, for unacceptable reasons. Which brings us to the topic at hand – safety first, everything else second.
The International Helicopter Safety Team (IHST) was born at the International Helicopter Safety Symposium held in Montreal, Canada in September 2005. This gathering of the international helicopter community took a hard, cold look at the international helicopter accident rate, found it unacceptable, and decided to do something. The goal is simple; reduce the international helicopter accident rate by 80 percent within the next ten years. The actual execution is extremely complex.
The international helicopter operating environment ranges from a small, VFR, two-seat piston engine helicopter-up to a large, 19-seat transport category helicopter, in IFR conditions with a two-pilot crew. Add to this just a few choices from the long list of potential helicopter missions, such as training, logging, EMS, corporate, aerial tours, aerial applications, utility work, offshore, photography, and of course, airborne law enforcement.
The IHST initiative is predicated on the highly successful Commercial Aviation Safety Team (CAST), which was a statistical analysis of available accident data relating to scheduled air carrier operations. As a result of the CAST research, the airline industry has, for all practical purposes, created an almost accident-free operating environment.
Although the task at hand for the IHST is much more complex, and must take in numerous variances not found in airline operations, I sincerely believe we can achieve an 80 percent accident reduction. When I hear reluctance to this goal as being too high, I simply ask, "Just flip the numbers around. Are you telling me a 20 percent accident rate is acceptable?" In fact the number should actually be a "0 percent" accident rate. When we wake up each morning no accident should be acceptable. I do not subscribe to the theory that "Stuff just happens. You cannot prevent everything." If you do not try, you will never know.
Now that we have set the goal, how do we intend to do this? Glad you asked. The IHST, which is a jointly sponsored effort by Helicopter Association International and the American Helicopter Society, is overseen by an executive committee, of which I am honored to serve on as one of the co-chairs. The other co-chair is Dave Downey, manager of the FAA Rotorcraft Directorate Office. We have an established intent to insure the participation of the entire international helicopter community, predicated on the theory that any accident is everyone’s accident.
To date we have created two working teams, a Joint Helicopter Safety Analysis Team (JHSAT), and a Joint Helicopter Safety Implementation Team (JHSIT). The JHSAT has been in the process of meeting four days each month to analyze available helicopter accident data and to determine the trend of causal factors, and contributory issues. The JHSIT, having just been formed, is about to commence a review of the initial work of the JHSAT’s analysis process, and start the formulation of recommended implementation initiatives to reduce the international helicopter accident rate.
Where do you fit in? Good question. To date the activities of the executive committee, the JHSAT and JHSIT have involved participation by individuals from every segment of the international helicopter community to include, regulatory agencies, helicopter operators, manufacturers, research organizations, academia, the military, and HAI Affiliate Members, such as APSA’s very own Keith Johnson, APSA Safety Program Manager. We are at a phase now where various specialty-working groups will begin to be populated with ladies and gentlemen such as yourselves, who have expertise in specific operating profiles. In your case, airborne law enforcement, and the many associated mission activities you conduct on a day-to-day basis. These working groups will assist the IHST in our review of the data and formulation of recommendations, a reality check, as I like to call it. Open participation will also be fostered via the Internet, by allowing anyone interested in the IHST initiative to go to our Web page at WWW.IHST.ORG, review the program, and post your thoughts.
While I have the opportunity, let me impart some of my personal thoughts regarding this effort. I believe the greatest challenge for IHST will be the presentation of the cost/benefit analysis or business case, to those involved in the ownership, management, production, flight, maintenance, and use of helicopters. It is our responsibility to clearly demonstrate that there is not only a humanitarian incentive in preventing accidents, in terms of the elimination of fatalities and injuries, but a strong business case to be made for a cultural mindset change with regard to safety.
Bottom line-no accidents, no fatalities or injuries, which is the primary driver for this effort. However, we must also realize that such efforts regarding safety enhancement initiatives, also involve the potential of additional costs, which is a legitimate concern to commercial operators having to insure the financial health of their organization, and competitiveness in the open market. This also includes the education of the client base, who must pay for our services.
I sincerely believe we can demonstrate that the return on investment relating to initial economic outlay for safety initiatives can reduce the actual costs, and increase revenues over the long term, when you consider the many negative effects of a helicopter accident, outside the loss of persons and aircraft. Some of these additional detrimental effects of an accident include, loss of the aircraft as a revenue-producing asset, negative perception of the helicopter industry by the general public, clients, regulatory agencies, insurance industry, and the press. All of this resulting in strong opposition to requests for heliports, new or expanded operations, and airspace access. Also, higher insurance rates, high judgments from litigation, a reluctance from the client base to continue the use of helicopters, or a decision not to use helicopters by potential new clients that we do not even know about. Simply stated, "If you think the cost of safety is too high, consider the cost of an accident."
In the end, guys like me can preach all we want, and people like you can agree safety is a good thing. However, until we all truly believe safety is first, second to nothing, and practice this cultural mindset every day without waiver, we are not going to be successful. In the reality of operating helicopters that means we have to be willing to set the standards and not blink. It means we might not be able to complete every flight or assigned mission. For commercial operators, you might have to walk away from a contract or client that demands service without attention or regard to safety. For a corporate operator, you might not be able to get the boss to that critical meeting, and he might not be a happy camper in some cases. For the aerial tour operator, you might not be able to make that ride as dramatic and inclusive as you want, but you will still be able to deliver a life-long memory to the customer. For the EMS operator, it is possible that the child waiting to be airlifted might not make it without your transport. However, you will not cause the loss of additional life due to your sincere concern for the patient by using faulty aeronautical decision-making.
Let us never forget our ultimate mission, much like the medical community, is "do no harm". Be mindful we cannot complete every mission, but those we do perform can and should be done safely. If we get everyone onboard, we can succeed.
As always, let me know what you think. I would sincerely appreciate your comments and thoughts, just forward them to me at TAILROTOR@AOL.COM. Remember to fly safely and neighborly.
To the ladies and gentlemen of APSA, you have my sincere appreciation and respect for what you do everyday on behalf of all of us – thank you.
Matthew Zuccaro is the President of HAI. During his 35-year aviation career, he has held several executive level and operations management positions with commercial, corporate, air tour, scheduled airline and public service helicopter operations in the northeastern U.S.
Assessing & Managing Risks
By Keith Johnson
APSA Safety Program Manager
Risk management is the identification and control of risk. Good risk management minimizes risk to an acceptable level when weighed against the benefit of completing the mission. It’s the most important thing we do. Risk management is everyone’s job and is the key to safe, professional operations.
Safety principles that provide the foundation for managing risk include:
Always operate in the safest manner possible.
Never take unnecessary risks.
Safe does not mean risk free.
The key to safety is the identification and management of risk.
There are five elements of risk and general ‘rules of thumb’ to consider. This includes knowledge, skill, judgment and experience. With regard to aircrews, for example, there should be minimum experience standards that should be met prior to assigning new personnel to the night shift. There should be more frequent proficiency training (check rides) for new pilots and tactical flight officers. Inexperienced personnel should not generally be assigned together. When most new personnel are assigned to law enforcement aviation units, they generally have little, if any, experience. Most could not get a job in the aviation industry. Training is the only substitute for experience.
Performance limitations, operation in the height-velocity curve, fuel state, suitability of aircraft configuration for performing the mission, maintenance compliance and airworthiness, and accelerated wear must be continually be evaluated.
This includes weather, terrain, surface obstructions and other aircraft in the area of operation. Ceiling and visibility standards should be increased for night operations.
This includes tactical incident management, surveillance, transportation, rescue, command and control and firefighting; all have different requirements including the necessary training and equipment required to safely perform these missions.
No matter their experience, management always has the responsibility of assessing whether to perform a mission or abort. In modern accident investigation, management’s role and responsibility is always assessed. Management is responsible for ensuring that appropriate written standards are in place that address safety, training, operations, organization, maintenance and administration. (The APSA Standards can be used as a guide.)
The importance of having primary and recurrent training for the missions being performed cannot be overemphasized. Too often, the excuse for not performing necessary training is that it’s too expensive. Try having an accident. If you’re lucky, you only destroy a $2-3 million aircraft. If you’re not so lucky, you have people seriously injured or killed. Now things get really expensive.
When it comes to training, there is a choice, but only one right choice. If you think you can roll the dice and hope you don’t have an accident, you are only denying the inevitable. Wishing and hoping is just that. It won’t prevent an accident.
In managing risk, you must identify hazards, assess the hazards, develop controls to minimize or eliminate risk, implement controls and constantly assess hazards associated with the mission.
Most of us have probably heard someone say, "I have been doing it this way forever, and I have never had an accident." I suggest that an absence of accidents does not necessarily equate to safety. Furthermore, familiarity and prolonged exposure without a mishap leads to a loss of appreciation of risk. We tend to assume that because nothing has happened, we are doing it right. The 26 people killed and the 118 injured in law enforcement accidents since 1999 probably didn’t take off thinking they could have an accident. And, they probably thought they were doing things right. We tend to think that having an accident is always going to happen to the other guy.
Sixty percent of law enforcement accidents occur as a result of human error and loss of control. Many accidents occur due to a convoluted belief of mission urgency and risk taking, causing judgment errors.
We are all subject to making such mistakes. Perhaps when we start flying, we start with a bag full of luck and a bag of experience. The trick is to fill up the bag of experience before the bag of luck runs out. So, what is the problem, and what are we going to do about it?
Judgment and action errors are at the source of most accidents. Therefore, all organizations must eliminate the motivation that causes people to be too focused on performing the mission and not focused enough on safety. The key to managing risk and eliminating accidents requires the following:
Taking a proactive approach to accident elimination.
Focusing more attention on flying the aircraft and on managing risk.
Learning to follow established procedures.
Managers must recognize that reinforced bad behavior breeds continued bad behavior. Managers must ask, "Are we rewarding the right people?" Intentional non-compliance with the rules generally does not result in an accident, but it always results in greater risk. The organization must eliminate the motivation that causes people to break the rules by having a positive, healthy safety culture. We need to learn to do the right thing, for the right reasons, at the right time, every time.
We must always beware of the "can do syndrome." Rationalization of the gravity of the situation seems to lessen risk in our minds, but in reality, it does not. Any change in the risk associated with accomplishing the mission requires the reassessment of risk. We must make a distinction between a body recovery and a rescue. We must not fall prey to the expectations of others, including higher ranking officers, politicians, the public, peers and even self-pressure.
Poor crew resource management is often a contributing factor in accident causation. While the pilot ultimately bears the responsibility for the safe operation of the aircraft, the tactical flight officer or other non-pilot crewmembers have an equal say when it comes to safety and the decision whether to attempt or continue the mission. The EMS industry has adopted the following policy, "It takes three to go, and one to say no." Any crewmember must be able to abort the mission based upon safety considerations.
We need to identify unsafe flight profiles, including overestimating crew qualifications, the operating environment, mission requirements and aircraft suitability. Pilots need to spend more time flying the aircraft and managing risk and less time focused on the mission. The TFO is generally the one charged with managing the operation, not the pilot.
In assessing aircraft suitability, it is important to recognize that most of the aircraft operated by law enforcement are light, single-engine aircraft. This makes aircraft performance an important issue most of the time. When we add people and equipment beyond a crew of two, (e.g. rescue, personnel transportation and airborne use of force to name a few), we are operating at or near the limits of the aircraft’s capability. This requires careful consideration when deciding what sort of missions the organization is going to perform.
One of the reasons we are in the law enforcement business is that we are mission oriented. This is good, but we must be careful not to become too task oriented at the expense of good risk management procedures. We must remember that even the simplest mission has risk. I read in a recent edition of Heliprops that manager John Williams of Bell Helicopter stated, "The helicopter has absolutely no respect for the number of years I have flown or the fact that I have an ATP rating. It can be an equal opportunity killer. I keep that in mind every time I crank the engine." This is something we should all consider. And, it is equally applicable to fixed-wing aircraft.
At the foundation of good risk management is attitude. Ralph Waldo Emerson wrote, "What lies behind us and what lies before us are tiny matters compared to what lies within us." People are the key to managing risk and eliminating accidents. We must focus on making good decisions. Going home at the end of our shift should be our highest priority, not the mission. A bad guy that escapes today will be caught tomorrow.
If you think that risk management gets in the way of accomplishing the mission, the opposite is true. Managing risk, more often than not, enables us to accomplish the mission. And, if after considering all of the risks we cannot manage risk to an acceptable level compared to the benefit achieved from accomplishing the mission, we should not attempt or continue the mission. By managing risk and making good decisions, accidents can be eliminated.
Create A Safety Culture
By Jay Fuller
APSA Safety Staff
Most of us already understand that safety works and safety programs are necessary to ensure continuance of and compliance with safety efforts. A defined mission with written goals and objectives are the anchor for your safety program. The mission of any aviation safety program is simply to eliminate mishaps (i.e. accidents and incidents). Nothing short of this is acceptable. Perfection is not something we expect to achieve on a continuing basis, but assigning this as a mission ensures that efforts will always be made, regardless of our success rate. Let’s identify who should be in charge of your unit’s safety program and why.
Who is the Safety Officer?
The safety officer is the heart of a unit’s safety program. This is a staff position, which means the individual(s) assigned have no line authority. He or she is selected by and reports directly to the unit chief (not to operations) and derives authority from the unit chief. In small units, where the unit chief is functionally the head of operations, this situation must be addressed through the relationship of the two individuals.
The safety officer provides internal unit oversight, which is not compatible with line supervisory responsibility. However, it is entirely appropriate for the safety officer to be a line pilot or a line tactical flight officer. In large aviation units, it may be feasible to have a purely administrative position. Knowing and understanding the day-to-day work of aviation crews is crucial to being effective in the job of unit safety officer.
Who are Good Safety Officer Candidates?
Potential safety officers should be interviewed with specific duties in mind and selected by the unit chief based on their interest in safety, line experience, credibility within the organization, good people skills, a willingness to do administrative program work and mutual trust with the unit chief.
The safety officer is dependent on the unit chief for authority, and the unit chief is dependent on the safety officer to provide much of the internal unit oversight. The latter means that on occasion a safety officer must be able to tell the unit chief things he or she doesn’t want to hear. Consequently, there must be complete confidence and trust within the relationship.
Once selected, the safety officer and unit chief should agree on an initial duty set, reasonable job objectives and a reduced operational workload for the safety officer in order to make time for increased administrative responsibilities.
How Much Time Should a Safety Officer Commit?
Under most circumstances, the safety officer position is a four to six year job. Over this time frame, most people start losing the energy and motivation it takes to maintain a proactive program. At the same time, personnel within the flying unit will become somewhat immune to messages from the same individual. After a tour as safety officer, it is very reasonable for an individual to return to line function or gravitate into command, depending on the needs of the organization. Not only does it provide new blood and new ideas, it increases the number of unit personnel having experience with and an appreciation for the safety program.
Who Should Know About the Position?
Once selected, the safety officer must be appointed in a very public way. The unit chief should make a formal announcement at some unit staff meeting, specifying some of the duties and affirming that the safety position has full support of his or her office. This should be backed up by a memo outlining the same information for individuals not present, for outlying stations, if any, and for future reference. This same memo should be up-channeled by the unit chief to higher agency headquarters for distribution to both command and staff personnel.
Should We Establish a Safety Committee?
If the safety officer is the heart of a safety program, the safety committee is the brain. Since the safety officer is appointed by the unit chief, the safety committee should be as well. Committee members should be selected so that all identifiable aspects of the aviation unit are represented. This is easier than it sounds. In the small unit where staffing may be a problem, individual members typically wear multiple hats anyway. The safety officer will be the chair and typically can represent flight operations. Other prime candidates would be additional flight ops personnel, senior maintenance, line maintenance and line service personnel (depending on the size of the unit and breadth of missions). Beyond this, if service such as fueling is provided under contract, contractor personnel would be qualifiers. Significant aviation user groups, either inside or outside the police agency, would be another source. It isn’t necessary that committee members be aviation unit assigned.
The criterion for selection is regular involvement with aviation unit activities and a "stake" in the unit or its missions. Using non-unit assigned personnel also relieves the staffing burden for small aviation units.
Do Meetings Enhance Communications?
Meetings should be held on a regular, scheduled basis. Semiannual meetings are a realistic, workable minimum. As chair, the safety officer or their designee should make up the agenda. Agenda items should be sought out from the other committee members and unit personnel if the opportunity and unit structure permits. Advertise meetings at least a month in advance. It doesn’t hurt to poll individual committee members and unit supervisors ahead of time about potential dates to avoid conflicts with vacations, training or scheduled unit actions.
Keep meetings structured and adhere as much as possible to a firm time schedule, as attention levels tend to drop after about two hours. The chair needs to maintain control, since efforts to elicit input often bring out the "soap boxes." Have someone serve as recorder to document meetings. Start off with open items from the previous meeting, continue with new agenda items and finish with any input from the floor.
How Should We Get the Word Out?
After the meeting, write up the minutes and brief the unit chief and other supervisors as appropriate. If the committee came to specific conclusions so that recommendations involve action by management, make sure that all details are covered and the basis for conclusions is clear. In this case, it would be best to have two or more of the committee members available during the briefing. Once all issues have been settled between the committee and management, the minutes should be made available to all personnel. Since some of the issues discussed may be sensitive, either within or outside the unit, a summary of issues covered would be permissible. For recommendations that have been accepted by management, implementation becomes a line responsibility.
Why Should We Follow Through with Initiatives?
Following up and monitoring directives from the safety committee, either directly or through line management, is a safety function. The three most important factors to ensure the implementation and effectiveness of safety program efforts are follow up, follow up and follow up. This means ensuring (along with line management) that all prescribed actions are in fact taking place, monitoring to see these actions are generating the desired result and if they aren’t, calling for modification or even elimination of the action
Night Missions - Operating Low & Slow
By Paul Osterman
Safely operating a helicopter in the areas where they provide their greatest benefit – the low and slow environment – requires being fully aware of many factors. Helicopter pilots achieve this state, known as "situational awareness," primarily though visual reference. Hoisting operations, search and rescue operations and even normal patrol activities require that a helicopter pilot be aware of obstacles, flight paths to avoid those obstacles and the movement of the helicopter, all of which must be recognized visually.
Therein is the problem. During night operations, the visual system is incapable of maintaining the necessary situational awareness for helicopter pilots to be able to perform the low and slow mission safely. Fortunately, through the use of modern night vision goggles (NVGs), pilots can overcome this visual deficiency during night operations.
The absolute safest way to deal with night operations is simply not to go. This has been the operating procedure for many law enforcement agencies where the risk of operating at night in certain locations was simply too dangerous to accept because of poor visual acuity or dangerous obstacles. Modern NVG technology has started to change this fact by allowing helicopter crews to have more visual references and increase their situational awareness. In areas where pilots previously had no visual references, NVGs produce an acceptable visual picture where not only are the obstacles visible, but so is the surrounding terrain.
NVGs, however, are not a perfect solution to the problem of night visual acuity, and they come with limitations. This is where the aviation managers in today’s law enforcement agencies need to fully educate themselves before either turning down NVGs or embracing the technology. It is paramount that they look at what capabilities they wish their organization to have and how they can safely perform them. If they are about to embark on a modernization program for their department, then NVGs should be evaluated as a possible solution to night deficiencies.
Properly modified cockpit lighting with current NVG technology and properly trained crews could give most agencies a safe way to approach new night missions or capabilities. For those agencies looking to add new night missions to their operations, especially away from urban areas, then NVGs should be considered. Education remains the key in this process, so managers should seek out other agencies that have already obtained this new technology and learn from their experience, or contact any of the certified training schools for additional information or a demonstration.
Gaining NVG capability should include three things necessary for a safe program: modern goggles, helicopter lighting modification and crew training.
To be able to provide the safest capability, it is necessary to include modern NVGs. These come by many different names and designations, and decision makers need to ensure that they purchase current high quality goggles. ITT and Litton build military grade devices, and these should be considered first. You will hear names like ANVIS-6(V3), ANVIS-6(V3)-gen4, ANVIS-9, M-949, Pinnacles and others. PVS-5, PVS-7 and ANVIS-6 designations refer to older generation or non-aviation NVGs, which are unacceptable and unsafe for most urban or near-urban operations. Seek a reputable dealer or inquire with a certified NVG training school for additional information before purchasing any generation night vision goggle. Older night vision goggles have poor visual acuity and respond poorly to changing light situations.
The second part is making sure you have a compatible cockpit lighting arrangement. Taping over gauges or radio displays, or simply turning off interior or instrument lights is not a truly safe way to fly with NVGs. A properly arranged and compatibly lit cockpit makes it easy for a pilot to quickly see important displays when rapidly peering under their goggles. Requiring a pilot to use a lip light or flashlight to gain visibility with an essential display requires more "inside" time, and everything should be done to minimize the time a pilot has to spend inside, as it reduces time spent gaining situational awareness outside. During this modification process, consider converting exterior lights to modern LED versions, which provide a bit more compatibility to NVGs and are less likely to burn out or fail. The best way to obtain the safest aircraft and instrument lighting is to seek out a company with an approved supplemental type certificate for NVG lighting. This will ensure a system that has been approved by the FAA.
The final and most important part of this process is training. NVGs have limitations. Pilots need to be taught and shown these limitations. Modern NVGs have an amazing view, and it is easy to think that one can just slap a mount on their helmet and go use these devices, but to do so would be dangerous. While they restore central vision, which for all practical purposes is blind at night, NVGs take away almost 160 degrees of peripheral vision. To compensate for this, a pilot must learn to scan constantly during flight. This is not a natural process and requires training.
Additionally, while there are two tubes, NVGs do not provide depth perception; the eye is simply focusing on a green image inches from the eye. The eye together with the brain can learn to interpret depth from NVGs, but it takes time and training to learn the new cues. Pilots also need to experience what the night vision goggles can not do for them, like see wires or fences, items of similar contrast or the loss of discrimination when the goggles have auto-gained due to a bright light in their 40 degree field-of-view. A properly trained pilot will know all of this and will not allow these limitations to decrease their situational awareness.
Seek out an FAR-141 certified school for proper training. This isn’t to say that schools or instructors without FAR-141 certification provide poor or inadequate training, but a certified school has taken the extra step to seek FAA approval and oversight. This certification means that the school will have a properly modified training aircraft and use modern, certified and inspected NVGs. It will usually mean that the instructors have years of experience, which means that your pilots will receive an important logbook endorsement for their training. Additionally, while inquiring with the school about training, try to send tactical flight officers or observers. Often, they can attend at a reduced rate, and it is worthwhile.
Modern law enforcement has many capabilities and missions and continues to expand. Even if an operation is mostly an over-the-city type operation, it should not rule out NVG capability. Consider the recent blackouts and hurricanes like Rita and Katrina. Blackouts and natural disasters inevitably happen, and there may be no artificial lights for hundreds of miles. NVGs are the only safe alternative during these situations. Approach the decision with education, and build safety into any new capability. Accomplished properly, any agency can safely add NVG capability.
Reduce Aircraft Insurance Costs Through Safety
By Pete Torrell
Vice President, Nation Air Insurance
Insurance brokers can help airborne law enforcement units find the best insurance underwriter, and they can also help them organize their unit in a way that will make them more insurable.
It is extremely important to select an experienced insurance broker that can council a law enforcement agency on the necessary training requirements and minimum experience that will be favorable to underwriting.
Finding the best broker also can have a large impact on your insurance placement. You want your story told to the underwriting community in the most accurate and favorable light possible. A good broker will know which underwriters will be the best to talk to when searching for coverage tailored to your unique requirements.
Many underwriters do not understand the risk well enough to view airborne law enforcement units favorably. This could result in few underwriters offering quotes. But if a respected broker presents your insurance needs to the underwriters, you can expect more favorable terms and more options.
A broker who is experienced in insuring airborne law enforcement can give you guidance on how to improve operational areas that affect your insurability. Suggestions for improvements may include improvements to training facilities and practices. While budget constraints for these departments vary widely, most budget for at least some annual training provided by outside sources as a necessary cost of maintaining safety. Underwriters frequently require such training to maintain a unit’s insurability in addition to in-house training.
Another important issue is how and by whom aircraft are maintained. What types of standards are being used to maintain military surplus aircraft, and what type of experience does the mechanic have if maintenance is not outsourced? It is preferable that law enforcement departments also budget for mechanic training. Hopefully, the aircraft are maintained and operated in a manner that is consistent with civilian aircraft that have a standard airworthiness certificate. Departments maintaining their aircraft to Part 135 standards, or at least to Part 91 standards, can help mitigate liability claims from third parties in the event of an accident involving bodily injury or property damage.
A challenge we see for many units is that the unit manager lacks sufficient aviation experience. This can result in uninformed decisions that jeopardize safety and insurability. Safety is a culture that starts at the top of any organization. Managers must be committed to listening to trained professionals in areas they don’t fully understand and be committed to creating a culture where information flows in both directions. Proactive organizations will create a safety officer position that would be responsible for the following:
Monitor and advise all operator safety activities that have an impact on flight and ground safety
Formulate and initiate activities that stimulate and maintain flight, maintenance and line service personnel’s interest in safety
Facilitate safety meetings with all employees and senior management
Develop safety accountability procedures
Conduct detailed safety audits to help identify deficiencies and ensure established procedures are being followed
Improve safety policies and procedures
Manage the operator hazard identification and tracking system
Monitor industry flight safety concerns having an impact on operations
Maintain a safety awareness program (safety awareness is the heart of any safety program)
Interface with aircraft manufacturers and industry safety associations
Establish operator emergency response plan
Investigate incidents/accidents and make recommendations to management to prevent a recurrence
Measure the results of initiatives
Meet with senior management each month to review the status of the safety program
The safety officer should have operational experience, normally achieved as a crewmember, and receive training in the following:
Flight safety philosophy
Human factors and the decision making process
Safety management systems
The role of the safety officer as advisor to senior management
Emergency response planning
In smaller departments, this person might have additional responsibilities, including pilot duties. Your broker may be able to refer a safety and loss control consultant to you. Some underwriters will provide this consultant at no charge to you if your broker asks for the service.
A good unit manager can manage more effectively if he does not let ego get in the way of making informed decisions. Hopefully, managers that lack aviation safety experience will listen to input from their chief pilot, safety manager and mechanic and trust their judgment. Further improvements will result by sending the unit managers to an APSA management course. Hopefully, these unit managers will not be rotated into other departments too quickly lest the decision-making process remain in a continually inexperienced state.
It is important that your broker is familiar with your safety program and is apprised of any new actions and improvements that have been accomplished each year. This will ensure that you receive the benefit of all credits available in the rating of your insurance premium.
The aviation insurance market is presently headed into a more aggressive and competitive cycle. This is due to the return on investments, current profitable insurance rates and overall favorable loss experienced by the underwriters. Some of this has created incentives for new underwriting facilities to start up, which will bring more competition to the marketplace resulting in a downward trend in premium costs in the near future.
A good aviation insurance broker will help you leverage this situation to maximize your insurance value. The present market is an opportunity to broaden your amount and types of coverage. This might include admitted liability, including crew. This can serve as a valuable employee benefit for crewmembers that find it expensive to purchase life insurance because they are pilots. A suggested minimum is $250,000 per person, including crew. It is also a good time to consider increasing liability limits. There are many other extensions of coverage that are available at little or no cost but are not given unless asked for. An experienced broker will negotiate those into your placement.
The TFO Role in Flight Safety
By Jack H. Schonely
LAPD Air Support Division
Situational awareness increases with an extra set of trained eyes, as long as communication is open and encouraged between pilots and their tactical flight officers (TFOs), crew chiefs and paramedics.
One of the many positive things the Sonoma County (CA) Sheriff’s Department Air Unit practices with regards to safety is the involvement of crewmembers in keeping the pilot informed. Their pilots verbally request a sterile cockpit during departure and approach to the airport, but they also request that the crew assist in collision avoidance by calling out traffic and obstacles. This includes both the TFO in the front left seat and the paramedic in the back. It works very well, and it is the everyday practice of these professional aircrews.
When thinking about the safety of a flight, most would picture a pilot at the controls making decisions and smoothly flying the aircraft. The pilot ultimately is responsible for completing a safe flight; however, he or she is only one piece of a larger puzzle that completes a picture of safety in law enforcement aviation.
But before others – particularly TFOs – can contribute to safety, they need to understand their role and receive information about the aircraft, emergency procedures, obstacle avoidance, weather minimums, collision avoidance and overall air crew coordination. But most importantly, they need to know that they have a voice in the decision making process.
Let’s look at this in one of the most common scenarios that aircrews face – the "Go, No Go" decision. Many aviation incidents and accidents can be traced back to a poor choice to fly under a particular set of circumstances. A pilot receives training in weather and certainly understands FAA and agency weather minimums. The TFO should be briefed on current and forecasted weather prior to start up, and he or she should raise any concerns immediately. TFOs will not be as effective if they are uncomfortable with the weather conditions. Their concerns should be discussed with the pilot in command. In most cases, the pilot can ease concerns by talking about the situation. The TFO’s concerns also may result in the pilot slowing down and rethinking the decision to fly in marginal or poor weather. This should be a crew decision for optimal safety.
In-flight emergencies can be very stressful and require prompt, correct actions by the pilot for a safe conclusion. How many TFOs carry an emergency procedure checklist with them in flight? This is a simple practice that can dramatically increase safety during any procedure. It allows the pilot to keep both hands on the controls and concentrate on the emergency while the TFO looks up the procedure and reads it aloud. This is particularly helpful during a situation involving hydraulics or any binding of controls. In addition to reading out the procedure, the TFO should have some familiarity with the various gauges so he or she can assist the pilot in monitoring an instrument if requested to do so. This practice does not require extensive training, but it can pay back big safety dividends if done correctly.
Collision avoidance and obstacle avoidance are two areas where the TFO also can make contributions to the safety of flight. The TFO should never assume that a pilot has seen an aircraft or obstacle and speak up and advise the pilot of what he or she sees. In many cases, accidents occur when both the TFO and pilot’s eyes are locked into a situation on the ground, and airborne objects, such as wires, are struck.
Open communication inside the cockpit is required for the safe operation of aircraft. The pilot plays a large role in the success of open communication by showing that he or she is receptive to observations and ideas by fellow crewmembers. They should thank the TFO for pointing out an obstacle and never imply that the TFO was foolish for pointing it out. Invite the information, and this will establish a safe culture within the cockpit that will apply to many other areas of safety and crew coordination.
Unit managers must set the tone for this safety culture that involves both the pilot and the TFO. They must take the training of TFOs seriously and not limit the training to FLIR and other mission equipment. TFOs should be involved in safety training, crew resource management and human factors training at every opportunity.
The pilot in command has many tasks and decisions that he or she is ultimately responsible for. Pilots should make an informed and correct decision in every aspect of each flight to complete it safely. Many sources can provide that information, including maintenance books, DUATS, preflight, information at roll call, prior training, experience and weather observations. But do not forget the valuable source of safety information sitting right next to you, the tactical flight officer.
Jack Schonely is a pilot with LAPD Air Support Division. He is a former TFO and K-9 Handler and a frequent instructor for APSA. His recently released book entitled "Apprehending Fleeing Suspects" is available at his website,www.officertactics.com.
Threat & Error Management:
You Can’t Prevent What You Can’t Predict!
By Craig E. Geis
California Training Institute
A detailed analysis of the law enforcement accidents over the past 13 years shows that human factors accounted for more than 90 percent of the mishaps. That doesn’t mean that only the pilot made the mistake. Maintenance professionals, manufacturers, management, etc., should also be considered when addressing the issue of human factors.
Four factors are important to understanding the interrelationship between discipline and safety: human error, negligent conduct, reckless conduct and intentional rule violations. These categories represent the principal labels we use socially and legally to describe blameworthy conduct. One or more of these behavioral categories will be applied in most mishap investigations, and the label often determines when disciplinary sanction is appropriate. Here are some short descriptions of these behavioral categories.
Human error is a social label. It is generally agreed that the individual should have taken an action other than what they took and, in the course of that action, inadvertently caused or could have caused an undesirable outcome. Human error is a term that we use to describe our everyday mistakes or behavior – missing a radio call or forgetting to bring a piece of equipment. The threshold for labeling behavior "human error" is very low – we make errors every day with generally minimal consequences.
However, keep in mind that human errors can cause catastrophic outcomes if the environment is unforgiving. Individuals and organizations often view a serious, adverse outcome as more important than a less serious one. This is known as outcome based behavior.
Some organizations and individuals focus on the outcome of an act and not the behavior or the individual. Regardless of the behavior, if the outcome is favorable, organizations often praise or reward the individual. If the outcome is unsatisfactory, they often punish the behavior, even when an honest mistake was made. But when looking at the consequences for this behavior, remember that punishment is not effective, because the behavior is unintentional. It is the normal byproduct of human action. Better policies, procedures, SOPs, training, task selection and structuring of the environment will make errors more unlikely to occur.
Negligence, at least in social dialogue, is conduct subjectively more culpable than human error. It is the failure to recognize a risk that should have been recognized. In most cases, negligence is defined as failure to exercise the skill, care and learning expected of a reasonably prudent person. It is the objective determination that a person should have been aware that they were taking a substantial and unjustifiable risk toward causing an undesirable outcome. Accountability for one’s actions is important; however, punishment in this case is usually not as effective as training and increasing awareness so the individual can better assess the risk.
Reckless conduct, alternatively referred to as gross negligence, involves a higher degree of culpability than negligence. Reckless conduct involves a conscious disregard of risk. Reckless conduct differs from negligent conduct in intent. Accountability in reckless conduct is critical. Since it involves a conscious disregard of risk, additional training is almost useless. Since the individual makes a conscious decision to disregard the risk, punishment is often warranted and appropriate.
Intentional Rule Violations
Most rules, procedures and duties will require or prohibit specific behavior. The intentional rule violation occurs when an individual chooses to knowingly violate a rule while he/she is performing a task. This concept is not necessarily related to risk taking, but merely shows that an individual knew of or intended to violate a rule, procedure or duty in the course of performing a task. Stopping this behavior is of paramount importance.
While it only accounts for approximately 3 to 5 percent of the mishaps investigated, the consequences and effect on the organization and on the team are serious. These individuals usually have a pattern of anti-authority behavior and often need to find a new line of work. Since there was an intention to violate a rule, punishment is appropriate. Training usually does no good because these individuals are often repeat offenders and must be monitored carefully. Do not hesitate to remove them from the organization.
If you look at airborne law enforcement accidents, you will find that very few are the result of reckless conduct and intentional rule violation. That leaves human error and negligent conduct to consider. Remember that, in these cases, training is the remedy.
The primary objective of training should be to help individuals better understand why human error occurs so their awareness increases and the individual can better assess the risks. Individuals need to have a clear understanding of the source of errors in order to predict what may happen, and then take proactive measures to avoid the error. In most law enforcement organizations, this training should address pilots, tactical flight officers, other crewmembers and maintenance personnel. Human factors training has become an industry standard and is mandatory for all FAR 121 and 135 crews.
To help us better target the training, see the table at right for a more in-depth look at the root causes of the law enforcement accidents for the past 13 years. Also listed are several key points in each error of human error. This analysis does not include those accidents that are still under review with cause factors pending. Due to multiple cause factors in some incidents, the total is greater than 100 percent. For example, management may fail to properly supervise maintenance, and maintenance may use an improper procedure. Both factors would be considered in the analysis.
With this data at hand, training can address the relevant error threat. The most effective training program to address these issues includes the following areas:
Accident Causation – Root Cause Analysis
Threat and Error Management
Stress and Performance
Low vs. Moderate vs. High Stress
Developing a Mental Model
Interruptions and Distractions
Channeled Attention to Fixation
Effective Critique and Feedback
The goal of human factors threat and error management training is to better help our team members predict, detect, avoid and recover from error. It accomplishes this by helping individuals better understand why human error occurs so their awareness increases and the individual can better employ human error risk management strategies.
Pilot Human Factors Key Points
While they account for 33 percent of the human factor mishaps, most flight skill errors result from a judgment error, which puts the pilot/aircraft in a situation that makes recovery difficult with normal skills. Therefore, you won’t fix the problem by seeking a training program. Skill training is obviously important, but consider targeting some of your budget on those areas that represent the greatest risk.
Most of the non-compliance errors reviewed go beyond simple human error, as defined earlier.
Most controlled flight into terrain and spatial disorientation mishaps start with a judgment error to proceed into marginal conditions, and the pilot does not have a plan or the skill to recover.
Most loss of tail rotor effectiveness mishaps start with a judgment error that puts the aircraft in a situation that requires too much power to recover.
Most supervision mishaps occur during training where the instructor fails to properly supervise the student or allows them to exceed A/C limits, making recovery difficult.
Material Failure: 33%
Loss of Engine Power: 10%
Component Failure: 15%
Most loss of engine power mishaps occur in military aircraft. Since 1999, 54 percent were in certificated aircraft. In most cases the cause was not determined and when tested, the engines ran fine. Pilots flying military surplus aircraft should be prepared at all times for a forced landing.
Component failures are balanced between maintenance-related causes and just plain material failure.
Maintenance Human Factors: 9%
Procedural Error and Failure of Quality Assurance Checks
These are mostly caused by not following approved procedures and failure of a good quality assurance check after maintenance has been performed.
Management Human Factors: 11%
Failure to Monitor and Properly Supervise Flight Operations
Management is responsible for planning, organizing, directing, controlling and staffing of the entire flight operation. In 11 percent of the mishaps, management failed in these responsibilities.
This figure may be skewed by the fact that, in many cases, management of law enforcement agencies is performed by non-pilots, and by default some of those management functions reside with the line pilots.
A safety officer is the manager’s best tool in this area. They can keep management up to date on problems, and a good safety program can provide the commander with the tools to effectively manage the unit, even if they are not pilots.
Manufacturer Human Error: 4%
When in doubt about a procedure, check it out thoroughly before proceeding.
What Should Safety Leadership Look Like In Your Organization?
By Roger Baker
President of Safety Focus Group, LLC
When asked, almost every person working in aviation organizations will tell you that the number one value and priority is safety. When pressed to explain how employees would prove that value to an outsider, they sometimes hang their heads and begin to fidget in their chairs.
An outsider could examine the aircraft, facilities, training, maintenance and other obvious signs of a safe organization. However, these indicators do not necessarily mean that a positive safety culture exists in that organization. A positive safety culture exists only when the management and staff know that each employee does the right thing, for the right reason, at the right time, every time.
As an example, suppose pilots see a thunderstorm in the distance (maybe 50 nautical miles or greater) and know that they should avoid the center and edges of the storm (the "right thing") in order to prevent discomfort to the passengers and damage to the aircraft (for the "right reasons"). The pilots plan to skirt the storm widely from the distance of 50 miles (at the "right time"), as opposed to waiting until they begin to feel turbulence and rain as they enter the storm.
In another situation, a maintenance technician might know that he must work on an aircraft structure that is high off the ground. He should procure the proper work stand (right thing) because it will correctly support him and his tools (right reason). The technician brings the stand to the aircraft before beginning the job (right time), rather than when his stepladder feels uncomfortable during the task.
These examples suggest that organizations should not only put safety into practice when someone is watching, when it is easy, convenient or at no cost. Organizations should constantly put safety into practice because it is the right thing for the right reasons at the right time. When this is typical performance and not the exception, then the organization has achieved a positive safety culture.
So how do you develop leadership to spawn this change in an organization and move from a reactive safety culture to a proactive positive safety culture? Three simple steps can make it happen.
The leaders and safety managers must evaluate the current state of the organization and where they want it to be in the future. This evaluation should examine the existing levels of teamwork and workgroup relations, the level of fairness and credibility of supervisors and managers, communications and the value that the organization places on safety.
The organization should identify leadership traits that should be enhanced. Such areas include vision, management credibility, teamwork, accountability, communication, action and providing feedback and recognition to the workforce.
After creating a specific plan of action and a clear vision of the safety culture goals and objectives, the organization needs to develop a positive plan to enhance the skills of supervisors, managers, and safety professionals to meet its safety strategic goals and objectives.
Putting the cultural changes outlined above into practice takes vision, a willingness to recognize shortcomings and a clear design for management and supervisor skill enhancements. Change leads to additional risk, however, it also brings great opportunities for improvement.
This process is hard work and cannot be undertaken without strong commitment. The process might require that the organization seek outside assistance with steps one and two. After developing a plan, the organization may require additional outside assistance in teaching the management and supervisors the skills necessary to improve the safety culture.
Most aviation organizations perform the operational requirements of aircraft and passenger movements well, however, many are not well equipped enough to bring positive change to the safety culture. Although most managers and supervisors grow into the job, after being picked from the general workforce, they require professional, formalized training in people and management skills in order to strengthen their abilities to lead in critical safety areas.
Many managers and supervisors believe they are too busy for classroom training, and ego can keep them from admitting they need skill enhancements. But if they truly wish to change the culture, they must first change themselves. Pretending to already have the necessary knowledge and skills will inevitably delay the change process.
Roger Baker is president of Safety Focus Group, LLC. The company specializes in safety audits and training, team performance, and safety consulting. He retired from the FAA after 29 years as a safety professional.
So, Who Does Train the Trainer?
By Randy Rowles
In a quest for a homework free weekend, a determined nine-year-old once offered me an interesting challenge. He looked me square in the eyes and said, "I bet the teacher doesn’t have any homework!" Of course, I explained that the teacher had tests to grade and classroom preparation to do for the next week. This little exercise of mental chess certainly got me thinking about aviation's instructor corps. The question that came to mind – so, who does train the trainer?
As a flight instructor, you have 24 months until you must renew your certificate. The Federal Aviation Administration (FAA) offers a high pass rate of applicants through instructional activity and personal knowledge of instructors, among other things. In addition, an instructor also has the option of attending a 16-hour Flight Instructor Refresher Clinic (FIRC). The FIRC is an FAA-approved program that provides detailed instruction on the "how to’s" of instructing and a comprehensive review of material such as Federal Aviation Regulations, weather and other important information. Many FIRCs are available online and provide a convenient method of compliance for instructors to renew their certificates.
However, FIRCs only meet the ground portion of FAR 61.56 Flight Review requirements. The instructor must then meet a proficiency check by either completing the flight review portion or passing an operating certificate holder check (i.e. 135.293/299 check ride) or other pilot certificate check in accordance FAR 61.56.
Essentially, the instructor is not required to demonstrate instructional competency; only pilot competency at the level of the certificate they hold is required. Within this line of thinking, you must assume that there is no loss of capability or degradation of instructional skills with time. Is it safe to conclude that once you obtain your instructor certificate, you will never again need flight training related to the safe and effective transfer of flight skills and related procedures? To make the assumption as described, you must believe that the training program of the instructor was adequate to support life-long instructional knowledge and flight proficiency. We all know that the human element will not allow this to be true. It is not by chance that human factor related accidents account for over 70 percent of the accidents in general aviation.
Several universities have done studies on retention of information through their student body. One study enrolled 50 students, verifying that each had minimal knowledge of the subject matter to be presented. The class was a short, condensed one-hour presentation on material that carried both exciting and benign information. The class met again every week for a period of eight weeks to take an examination on the material presented. As you would expect, every week the retention of the material presented varied among the participants. Out of all of the participants, the average retention level was less than 20 percent by week eight.
We must accept the fact that without remedial instruction, our proficiency and knowledge base will degrade. Many instructors that I have spoken with on the matter use self-study as their method of updating new information or reviewing subject matter that they haven’t used in a while. There is no doubt that self-study is a powerful and effective tool, but a common misconception is that self-study is all-inclusive, and no other training is needed.
Although study time is required to fully grasp material, it is fully dependent on the individual perception of the material. How many times have you sent an email to someone only to have him or her perceive your intent incorrectly? If the email was the only communication, your message may have been lost in translation. But if a meeting took place to review the material contained in the email, you would have the opportunity to direct the perception of the individual down the intended path. Attending a periodic instructional session such as an FIRC provides both the material review and an evaluation opportunity to the instructor.
When was the last time you were really evaluated? For many instructors, it was many, many years ago. An evaluation is healthy in our business. It is a deterrent to complacency and provides purpose to our own training initiatives. In addition, evaluations provide a method of standardization. The Practical Test Standards are an example of maintaining a standard through evaluation. It shouldn’t matter who administers the evaluation, the standard should remain the same.
While I was conducting a Private Pilot examination a few weeks ago, the applicant asked, "is it scary to get in an aircraft with someone you don’t know and do these maneuvers?" I explained that you never let your guard down and effective communication is essential. I thought about those that I do pay special attention to, and some of the most unpredictable pilots I have flown with were high time ATPs and CFIs. The reason is simply, when they make a mistake, they do it with vigilance. Making mistakes with confidence, to the untrained eye, can seem as though the pilot intentionally put the aircraft in a bad situation. This is not often the case, as the individual is only doing what they think is correct at the time.
The helicopter industry is unique with regard to the qualifications of the instructor corps. Often, a student becomes a instructor without the benefit of industry experience or knowledge. In the normal flow of a civilian helicopter pilot career, teaching is often the first employment opportunity available. It goes without saying that some of the instructors that accept this type of position really don’t want to be there in the first place. Who really pays the price in this situation? The student will suffer in most cases.
When training to be an instructor, you focus mostly on teaching – essentially how to effectively transfer information and fly a helicopter. Once you obtain your CFI, you no longer get in an aircraft with a pilot that only pretends not to be able to fly. This person really can’t fly the helicopter and has no idea of what to do or not to do. They may just let go of the controls for no reason, roll off the throttle or just lock up on the controls with a bear grip that you can’t overpower.
This is what students do. They learn by making mistakes. You are asking them to make mistakes because you are teaching them to do something they don’t know how to do. On top of that, they have no idea what the margin of safety is for the aircraft or maneuver you are training for. If you take a new student and tell them you are going to demonstrate a hovering autorotation from 25 feet in a Robinson R22, on the first one they will be happy to ride along. It is called blind faith.
Flight instruction is a tricky business. It requires the instructor to always anticipate a mistake when the opportunity for a mistake takes place. It is very common to teach a hovering autorotation immediately after having taught straight-in autorotations. In this case, you should expect the student to immediately lower the collective. They will push that collective down with all their might because you, the instructor, have taught them "when entering an autorotation, the collective goes down." Luckily, this is easily corrected for if you recognize the opportunity for the mistake.
You must think each maneuver through and identify where, when and why these mistake opportunities can take place. Some potential risk mitigators are placing your foot against the pedal that you want them to apply during the entry to an autorotation. This will allow the student to make a correct pedal input, but stop the outward deflection of the pedal if they make an input of the incorrect pedal. Also, keep your hand on the collective, or "up stick." If the student lowers or raises the collective at the wrong moment, you are prepared to act immediately.
This is what the industry calls training the trainer. The question you must ask yourself before you get in an aircraft with any student is "Am I prepared?" Have you been taught all of the "what if’s" of your craft?
Remember, we break many more aircraft training for aircraft malfunctions than actual aircraft malfunctions. Learn what maneuvers can bite you and what point of the maneuver is the most critical.
One maneuver that comes to mind is stuck pedals. This maneuver is inherently dangerous because it has the mistake opportunity of conducting a run-on landing with the skids not in line with the landing surface. My question is, "If the maneuver is taught correctly, and the student can get the aircraft to a safe altitude of five feet or so above the landing surface, wouldn’t that satisfy the task?" Many times we continue to a point in a maneuver not because of value added to the student but our own pride. The instructor must know their limitations and apply those to the maneuvers and techniques of their methods.
No matter who you fly with, you need to know how to identify red flags. A red flag is simply a sign, a point in time that the instructor connects with the demonstrated performance of the student. Usually when a maneuver is going south, the instructor will begin to identify problems areas, such as airspeed, altitude, sink rate or other issues that will have a negative effect on the outcome or safety of the maneuver. These issues are red flags. To be an effective flight instructor, you must know your machine and how to identify red flags. This is where I find the greatest void in instructor’s credentials. Many instructors never receive how-to-teach training in models of aircraft other than in the machine they received their flight instructor examination. It is not uncommon for a pilot that holds a flight instructor certificate to become the designated IP in an air wing or flight department. Without the instruction necessary to properly identify red flags specific to new models of aircraft, the lessons learned can be very costly.
So when you take your annual factory training or whatever training program you are on, request a review of your flight instructor skills related to your aircraft. Sit in the appropriate seat and have your instructor point out where and when mistake opportunities can take place. Ask the question, "How should I teach this maneuver?" Don’t be intimidated or embarrassed to ask these questions. Remember, your safety and reputation depend on it.
Randy Rowles is an instructor pilot with Bell Helicopter Textron. In addition to being a Designated Pilot Examiner, He is a Master Flight Instructor by NAFI and the Chairman of the HAI Flight Training Committee with over 10,000 hours of helicopter experience.