Monday, June 27, 2011

June 27th

Fresh Air Matters... with Capt. Yaw

Imagine you are sitting quietly aboard a CR700 regional aircraft with sixty odd other folks, waiting to taxi out to the runway. It is dark outside, drizzle on the window, and you are just about to take a sip of the sour tasting orange juice that, it seems, can only be served on-board aircraft. The cabin crew are just walking down the aisle, smiling as they slam those overhead baggage rack doors, reminding you about seatbelts, when something rather violent happens. No, not with another passenger – and not the weather! You hear a large bang from the back of the plane and then the aircraft spins ninety degrees to the left – you notice that the engines are not even running and your orange juice bypassed your digestive system in order to greet your shoes! Well that is pretty much what happened a few weeks ago, at JFK airport, when an Airbus A380 taxied behind a parked aircraft and hit the tail of the smaller plane with its wingtip. Nobody was physically hurt, but it shows how much inertia the mammoth A380 has and how quickly you scare a lot of people - and spend an awful lot of money on repairs – if you do not keep an eye on your periphery!

It seems, however, that key lessons were not learned, and when the A380 tried to do a similar thing to a building in Paris this week; the building won. The demonstrator aircraft hit a building, damaging the building, but losing the tip of the wing, leaving it embedded in the side of the immovable object and embarrassment plastered across the faces of a lot of people. Many demo flights, and potential sales, were lost.

I guess with such a big machine there are considerations about how you manoeuvre – and accidents will happen. Learning from those accidents is the key. Incidents of aircraft hitting things on the ground are not new, and they will, undoubtedly, happen again – and the bill will add up – but procedures need to change to prevent more, and keep insurance premiums down!

Ideas are now rolling in about ‘wing tip cameras’, ‘proximity sensors’, ‘folding wing-tips’ and even one person on the web suggested ‘moving the cockpit to the wingtip’, which is not a practical solution, albeit a fun one! No matter how many additional safety measures you add, they are all fallible, and it will always come down, ultimately, to the decision making capacity of the human being at the controls – linked intrinsically to the procedures he must follow. The very decision to move the aircraft from A to B via C will always be made by a person.

I believe that all but a very tiny percentage of accidents are human error. That error can be mechanical – a badly machined part, a bolt not mounted the correct way, the wrong material used, etc. It can be ‘maintenance related’ – lack of oil, a worn part not replaced in a timely manner, lack of paint to protect from corrosion, etc. It can be locational, operating in the wrong place or the wrong weather or perhaps at the wrong time of day. Then there is the bad design component, as well as the bad use element!

However, the majority of accidents are simply ‘bad decision’ accidents, generally in breach of laid down procedures. The A380 accidents, noted above, are both in that category. Whether it is the pilot who made the bad decision or the person who directed the aircraft along the route, it was a combination of bad decisions – and possibly a lack of laid down procedure for this type. Some people talk about HPL, or Human Performance and Limitations. This is a part of studies for a basic pilot licence in some countries. The basis behind taking some time to understand the HPL in your industry is that people are people and they are the source of accidents and incidents – not the machines they operate!

One of the factors considered is stress. Some people actually perform better under stress, others flounder. Each person has a performance curve that relates to their stress level – and it changes constantly. When we are tired we may be more likely to make a bad decision when under light stress, yet the same level of stress on another day may heighten our ability to make a positive decision and quicker. Our bodies are under incredible demands - and mine seems to get more demands every day!

People are people and they make decisions based upon their training, experiences and rules. They are only able to process a certain amount of information at any one time, and need to establish ‘drill’ or ‘routine’ patterns to carry out complex tasks. For example, in a ‘standard’ emergency in an aircraft, a pilot has practiced so many times for it, the decision is instant and it seems that the controls are moved before the incident has even fully developed. We call this ‘experience’, but really it is ‘rules, training and discipline’. This is not for everybody either! Some people are not built to handle ‘engine failures’ in aircraft, they simply cannot process it, and so they need to consider alternative careers, or undergo a lot more training and ‘growing’. Nonetheless, some may never attain the ability to achieve the seamless ‘recovery and response chain’ that makes flying safe – and that includes taxiing the A380!

The pilots of the A380, being relatively new, have not got much ‘experience’ of taxiing such a large aircraft. However, there is room for some ‘precautionary’ training and ‘awareness’ – plus some new ‘rules’. Today, all A380 pilots are reading recommendations relating to taxi operations and will have heightened attention to those little wing tips a long way away behind them and on each side! Over the next few weeks, analysis will be carried out on the reasons behind these incidents – human factors will figure high on the list. New rules, procedures and safety training will be recommended and enforced. However, at the end of the day avoidance of future accidents will come down to human beings, in and around the industry, and their day-to-day decision making.

How often have we had an accident in or near our workplace, or even ‘nearly an accident’? Should we just say ‘oh well, accidents happen’ or should each and every incident generate a rethink of procedures, vigorous implementation of those procedures and then disciplining of those who fail to adhere to the procedures? We all know the answer, but I see, time and time again, accidents happen and nobody visibly take note of the reasons behind them, and worse still, far too many people around the accident site believe that they are ‘exempt’ from accidents and incidents – or blame them on some supernatural reasoning.

In the history of mankind it has become blatantly clear that the vast majority of accidents are preventable, with appropriate rules, training, maintenance and constant revision of procedures, as the environments we work in change daily.

Remember: Safety is NO accident, and accidents really do cost a lot more than safety enforcement.
 Capt. Yaw is Chief Flying Instructor and Chief Engineer at WAASPS, and lead Pilot with Medicine on the Move, Humanitarian Aviation Logistics ( e-mail

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