• This call was started with Walter Kraujalis introducing the guest speaker, Sonnie Bates, the incoming IS-BAO Program Manager replacing Jim Cannon starting July 1st. As most of us know, a major contributor to the growth and acceptance of SMS in our industry can be attributed to ISBAO. SMS is an integral part of the standards. Sonnie has been teaching the ISBAO workshops and participating in the review of all the audit reports.
• Sonnie opened by saying that for the listeners on the call and working with the ISBAO standards, IBAC really appreciates whatever feedback you can give to them. The IBAC staff compiles and processes all of the feedback into recommendations that are presented to the ISBAO Standards Board. Over the past 3 years that he has been a part of IBAC, there have been numerous positive improvements. They also get feedback from the auditors.
• Someone asked how many operators are ISBAO registered. Sonnie replied that over 700 operators are registered, including everyone that is a Stage One, Two, and Three. He said that right now there seems to be flat period of growth – that the number of operators that registered in 2013 has leveled off. He is not sure what the reason is for this. He thinks it might be the operators looking at the requirements and thinking they are too onerous. He would like anyone’s feedback on this. IBAC is focusing on facilitating the small operator to become ISBAO compliant and registered.
• Sonnie was asked what does he mean by “small operator”? He said that has yet to be definitively defined, but they are looking at the operator that has a single aircraft that is a medium size jet or smaller, likely less than 27,000 kilos. That weight class is used in the ICAO SARPS as a delineator of certain equipment requirements. They want to encourage small operators to qualify. They are concerned what the small operator might think about the costs of complying, but mentioned that often the insurance underwriters can give a break on insurance premiums.
• Continuing the discussion about the small operator, Sonnie said that an SMS does not need to be all that complex. The level of activity is only one level of measurement of the robustness of an SMS. For a small operator to have only one hazard report a quarter would not be unusual. What is important is whether the report was processed properly, with a root cause analysis, mitigation strategy, and follow up. He said to look at ICAO Doc 9859 Safety Management Manual [note: available at AeronomX.com/downloads] which has a great description of the SMS process. Whether an operator has 4 hazard reports versus 25 reports, there’s no difference in IBAC’s opinion. It’s about the quality of the report. He is talking about hazard reports that are more than low-grade hazards, for example the light bulb being burned out in the stairwell. Yes, adequate lighting is important, but it doesn’t take too much of a process to figure out to replace a light bulb. A hazard report should have an analysis, be assessed, and then controlled with mitigation. There should be somewhat of an engineering science to treating the hazard, especially for Stage 3 operators.
• Sonnie shared a story about a small operator that flew a single-pilot jet only about 150 hours annually and used some part-time pilots. The pilot told him that it was impossible for him to have a safety committee. Sonnie suggested that the operator look to some of his vendors that provide essential services and see if they would be a part of his safety committee. Try asking the contract pilot, the FBO where they were hangared, the maintenance vendor, and the pilot training facility. He said this operator did just that and later remarked how well it was working for him.
• When asked about the online SMS services available, what did he think about those? Sonnie said that they can bring a great benefit, especially to the small operator.
• It was then time for Q&A from the callers. One caller said they are currently a Stage 2 operator and are due for an audit in April. How is it handled now? Should they try for a Stage 3 and see what happens, or just stay a Stage 2, or can they leave it for the auditor to determine which Stage they should be?
o Sonnie asked why go for a Stage 3? It is OK to remain a Stage 2. However, the expectation for a Stage 3 is that they are capturing all of the active conditions affecting their exposure to risks. Latent conditions are the other type of process deficiency. [Editor note: the 2014 ISBAO Audit Procedures Manual has had much more information added that defines what a Stage 3 operator which be performing].
• Dave said that they are a Stage 3 operator, a small department, and have quarterly safety meetings. He said it is difficult to get participation from everyone, to get them to submit reports. He said that he has probably submitted most of the hazard reports.
o Sonnie replied that IBAC has been thinking about having a Stage past Stage 3, an operator that has matured to a point that they are interested and willing to act as a mentor to other operators. He hopes that with operators like this available, questions like these could be handles by these mentoring operators.
• That concluded the call. It was 30 minutes in length. Next call is Tuesday, July 8th, at 11:30am Eastern time. Thank you for your participation. Please let other Safety Officers know of the opportunity to join the call or to access these meeting notes.
• This call was started by Walter Kraujalis and dedicated to discussing the sad and unfortunate fatal business aviation accident occur since the last call two weeks ago, specifically the Gulfstream IV crash in the Boston area Bedford airport on Saturday, May 31. Three crewmembers and four passengers died in the crash. We all hold out our thoughts and prayers for the victims and their families.
o The purpose of discussing this event is not to try to figure out what happened. It will take an investigation to figure that out. Rather, I wish to discuss it from the standpoint that since the accident did occur, for those of us in the business of, or with responsibilities in aviation safety, what are we to do or think about this accident, if anything at all? Do we do nothing until the full NTSB report comes out? Or do we take some sort of action?
• Dave said that in response to the accident, their flight department took the opportunity to review what items they brief for takeoff and approach briefing. We have some new pilots. We don’t want to let the briefing get stale by saying “standard briefing”. We looked at the books again. We reviewed our callouts.
• Sam said that if we get too involved too early, we are only speculating. We don’t want some sort of knee-jerk reaction.
• Rick said they don’t operate a G-IV, but their owners asked our opinion as to what happened with the Bedford crash. We told them that it was too early to say exactly what happened, but that they too took the opportunity to review their takeoff briefings.
• Another caller mentioned that there has been mention of control issues reported by the crew.
• Dave mentioned that he was actually flying to Bedford today and they he fully expects one of the passengers to ask about the accident. He was interested in hearing what other safety officers were going to say on this call. He also mentioned that he had a relatively new copilot with him today and that he was going to talk to him specifically. To boost his confidence.
• Earl mentioned that in their ERP, they specifically do not speculate as to what happened. What happened in Bedford has not reach a conclusion yet. Sure, we shouldn’t be complacent, we should never get complacent. But it is important to not throw rocks.
• Rick mentioned that they had an event happen in their hangar. They ultimately performed a full root cause analysis. Before a root cause analysis, everything is just speculation. To change anything now is premature.
• Bob mentioned the book the Naked Pilot, about human factors for pilots. In the book, it says that generally the aircraft are reliable. Most accidents are a result of human error. Though it may be common to react by blaming the pilots, it is wrong. We could be chasing every speculation.
• Walter Kraujalis mentioned again that we are not trying to second-guess the pilots or anything that might have happened. I thought it might be worth talking among safety officers, that in light of there being an accident in our industry, what do we do? Nothing? Wait for the NTSB report? Or take some sort of action, and if so, what kind of action?
• Rick mentioned that maybe an EMAS system at the end of that runway would have changed things. It appears the ILS antennae system was a problem too.
• Another caller said that airfield operations should be working on this. I guess for Bedford it is a matter of how much it costs to install EMAS and how many bizav ops there are.
• Walter Kraujalis then tried to summarize how the discussion has gone so far. That we would tell our principals that it is too early to say what caused the accident. That we are on top of it, staying in touch with any news from the NTSB, the FAA, the OEM. When any news is released as to cause, we will act upon it. In the mean time, we have taken the measures to review our procedures that might be related to the accident including our review of takeoff procedures and looking at what runways have EMAS systems. Is that what I’m hearing from everyone generally?
• Mike said that he agreed, but they included paying some attention to passenger habits. To make sure the passenger’s seat belts are secure and using their shoulder harnesses.
• Dave mentioned that was a good point. To refresh passenger briefs. We don’t use cabin attendants, so it is important that the passengers properly prepare the cabin for takeoff and landing.
• Eric asked whether anyone provided safety training specifically to their key passengers.
• Rick said that they made a video themselves that the passengers could watch.
• Someone asked how they determined what should be covered in the video.
• Rick responded that they put a committee together to discuss and decide that.
• Wanda mentioned that any passenger that is new to their cabin attendant, ie they have not met them before, they give them a complete briefing that includes sterile cockpit, evacuation, everything.
• Walter Kraujalis again mentioned that our condolences go out to the families involved with the accident.
• That concluded the call. It was 30 minutes in length. Next call is Tuesday, June 24th, at 11:30am Eastern time. Thank you for your participation. Please let other Safety Officers know of the opportunity to join the call or to access these meeting notes.
• Walter Kraujalis is the presenter for two upcoming NBAA Workshops next month:
o IS-BAO Operations Manual Workshop, June 16-17, West Palm Beach, FL. Link http://www.nbaa.org/events/pdp/is-bao-flight-operations-manualworkshop/20140616/
o Management Fundamentals for Flight Departments, June 18-19, West Palm Beach, FL. Link: http://www.nbaa.org/events/pdp/management/20140618/
• Please send me a sample of your FRAT form and I’d be happy to post all of them as examples for others.
CAVEAT: It is difficult to get into much detail in writing up these meeting notes as to what exactly was discussed about each issue, so you are encouraged to join in on the next calls. Names are changed in this report for anonymity.
• Things got started with a question from a caller that mentioned that they were adding a King Air 90 to their fleet of charter aircraft. They normally have jets that are flown with two pilots and were researching the notion of flying the King Air single pilot. He said that they are finding there is conflicting information of the pros and cons of flying single pilot versus 2-pilot crew. He wanted to know what other callers thought. He also wanted to get ideas of how to plan for, and introduce, a single-pilot program. Some of the comments in response include:
o Even though a King Air is certificated for single-pilot, it can be crewed with two pilots any way.
o Most clients wanted to have a 2-pilot crew on their King Air most of the time. The market may demand it be flown 2-pilot.
o Helicopters are single-pilot certified and it is very common to be flown single-pilot.
o It depends upon the mission for the aircraft. Some missions may require the attentiveness from 2 pilots, while other flights may be flown single-pilot.
o Walter Kraujalis commented:
§ Obviously it is OK to fly the King Air single-pilot under Part 135. § IS-BAO standards do not prohibit single-pilot operations. There is an IS-BAO recommendation (not a required standard) to develop and implement single pilot SOPs.
§ Placing a second pilot into what is normally a single-pilot situation is not a good thing. The second pilot must be trained in CRM and then the PIC and SIC should have SOPs working coordinated as a 2-pilot crew. Just placing a second pilot without this training and coordination has a strong likelihood of being a distraction and inconvenience to the PIC and actually creates its own hazard.
§ As with any situation, from a SMS perspective, identify the hazards and associated risks with either operation, flying single-pilot or 2-pilot.
• Another caller mentioned the use of FOQA as a means of monitoring the performance, behavior, and following SOP by a single-pilot. The pilot knowing they are being “watched” will minimize the “cowboy” situation. Comments:
o King Airs normally are not equipped for FOQA. Perhaps a similar device might produce the same results, such as the Appareo device.
o FOQA must be used properly. The information from FOQA must be handled carefully, so as to not be a tool for management to discipline the pilot.
o FOQA can help identify issues that may result in modifying SOPs.
• Another caller brought up the issue of how do you maintain consistency of the SOPs across multiple bases of operation. How to manage that. Comments:
o It takes communication.
o Share pilots among the multiple bases. o Have a regular pilot meeting with pilots from each of the bases to specifically discuss the SOPs.
o One caller commented that they have multiple bases and they never had a problem.
o Pilots from the same company but from different bases could train together in the sim.
• The discussion swung to sim training. Comments:
o One should get FlightSafety and SimuFlite to train your crews to using your own SOPs, and not just theirs. We pay for their services, they should train us as we want.
o Remember, that Part 142 certification may require that the training vendor use the 142-approved training standards.
o One caller said that they have no problem having FlightSafety train them to their own SOPs.
• Another caller mentioned they use contract pilots. He is amazed to hear stories of other operators that do not send their SOPs to the contract pilot in advance. Comments:
o There seems to be an increased use of contract pilots these days, post-recession.
o One way to mitigate the use of contract pilots is to try to use the same pilots as much as feasible. Send them a copy of your Ops Manual and SOPs in advance. For the first time or two, pay for them to come out a day early to meet the pilot they will be flying with, sit in the aircraft with that pilot to get familiar with the configuration and go through the checklist and to discuss the Ops standards and SOPs.
• That concluded the call. It was 30 minutes in length. Next call is Tuesday, June 10th, at 11:30am Eastern time. Thank you for your participation. Please let other Safety Officers know of the opportunity to join the call or to access these meeting notes.
• Walter Kraujalis is the presenter for two upcoming NBAA Workshops next month:
o IS-BAO Operations Manual Workshop, June 16-17, West Palm Beach, FL. Link http://www.nbaa.org/events/pdp/is-bao-flight-operations-manualworkshop/20140616/
o Management Fundamentals for Flight Departments, June 18-19, West Palm Beach, FL. Link: http://www.nbaa.org/events/pdp/management/20140618/
• I want to continue to foster the dialog among Safety Officers. These conference calls are but one means to get together and compare notes. Some ideas:
o AeronomX has put together the Safety Officers Forum on LinkedIn. To join, go to this link: https://www.linkedin.com/groups/AeronomX-Safety-Officers-Forum7474525/about
o Let’s not forget about NBAA’s Airmail and the Safety category. Over the years, Airmail has proven itself as a useful tool for communication within our industry. I encourage Safety Officers to make more use of this category. Go to your subscriptions page on NBAA at www.NBAA.org/Airmail and make sure you are subscribed to “Safety”.
o If you know 2 or 3 other Safety Officers in other nearby flight departments, I encourage you to consider forming a local Safety Officer Roundtable. It can be whatever you want it to be. One informal approach is to get together for lunch once a month or a quarter, and talk about issues each of you are dealing with. Let me know if I can help in any way, by helping get groups together, or topics of discussion.
CAVEAT: It is difficult to get into much detail in writing up these meeting notes as to what exactly was discussed about each issue, so you are encouraged to join in on the next calls. Names are changed in this report for anonymity.
• The call started with a topic that was brought up at the end of the last conference call but there was not enough time to talk about it. The issue is: How do various flight departments handle the situation of calling the pilots during their rest period? Schedule changes and other things come up, so how do you let the pilots know without interfering with their required rest?
o Wanda said that their scheduling folks send an email to the crew to call in once they are awake to notify them of the changes.
o Mike said that their dispatchers handle as much as they can of the changes on behalf of the pilots and send an email to the crew about the changes. If the changes affect the time the crew needs to depart, they wait and time the call to coincide with when the crew should be waking up to handle the schedule change. This of course is presuming the crew has had adequate rest.
• Walter Kraujalis brought up a new topic. He said that on a recent SMS audit, he heard the client tell a story of how one of their best mechanics, the one that all the pilots wanted to work on the airplane, was discovered to be doing something out of line, not to procedure. The client commented “how could he do that?” In the interests of a “just culture”, shouldn’t the question be phrased, “how did WE do that?” If your best guy is doing something not to procedure, doesn’t that mean there’s a chance that ALL of your mechanics are doing it? Do we blame him, or do we claim responsibility? Claim, not blame. There must be some reason, some motivation, why this employee was doing it.
o A caller said that they have a small department and do monthly internal auditing checks as part of their subscription with ARGUS. They pretty much know what each other is doing. Nothing like this would happen here because people would get caught.
o Another caller said they have a chain of command. If something like this was going on, it would get caught. They would discuss what to do and how to handle the situation.
o Walter Kraujalis wanted to clarify the issue with a hypothetical situation. Let’s say this good mechanic was not strictly following the new tool control program. Sure he complied from time-to-time, but not always. And this time he didn’t and inadvertently left his flashlight in the hell-hole of the plane. One of the pilots on the next preflight discovers the flashlight and writes it up as a hazard report. The investigation figures out this mechanic left it behind and did not account for it with a tool check. What do you do with that mechanic?
o A caller said that they would have to make sure the mechanic understood the tool control procedure and maybe would shadow him for a couple of days to make sure he was complying. This probably wouldn’t happen at our flight department because we have the automatic tool boxes that account for each tool. We have to make sure he is doing his job.
o Dave commented that we would have to look at why the mechanic did that. Maybe we should check our procedures. Maybe there is a bigger problem with our tool control program, or morale, or proper supervision issues.
o Another caller said that they would look at their culture of what’s going on in the maintenance department. Everyone is supposed to be following routine company procedures. We would probably take action against this individual for not following procedures.
o Rick said that they would call their Safety Committee together, and run a root cause analysis.
o Another called said that if he was not following company protocol, he would get a letter to his file. We need to change his behavior. Employees need to care about rules. There must be consequences for those that break the rules.
o Walter Kraujalis asked what about the policy of no disciplinary action with hazard reports?
o One caller said that in this hypothetical, it was a pilot that wrote up the hazard report, not the mechanic. So the mechanic does not get the benefit of no disciplinary action.
o Dave said that we need to find out if the mechanic’s actions were deliberate or a mistake. We need to ask the mechanic directly. Maybe his actions were “endorsed” by someone. We would do a root cause analysis.
o Another caller said that we need to look at the whole picture. Why is our “best” guy not following procedure? What is our “worse” guy doing? Maybe there is something wrong with our procedure.
o Another caller said they would retrain the first time. Next time discipline. o Another caller said that they would investigate why it wasn’t important to that mechanic to follow procedures. Maybe we did not convince everyone of the importance and purpose for the procedure. The “best” person in a department is typically held out as a leader in the group.
o [EDITOR’S COMMENT: That is the end of the comments and just a quick note for clarification. The issue was not specifically about tool control programs, but was used only as a hypothetical situation to discuss the notion of “claim, not blame”. Yes, there are definitely times that employees should be disciplined for poor behavior or not following procedures. A couple of final thoughts:
§ It is important to honor the non-discipline policy – here the mechanic did not write the report, he didn’t even know he left the flashlight behind. So technically he specifically doesn’t get the benefit from the “Cloak of Indisciplinity” with writing a report. But what if he did, and said the tool policy was too onerous to work with?
§ It is important to understand “why” someone does what they do. Here your best guy was not following a procedure. Why? In a just culture, there should be the belief that we have good people working here, well-intentioned, welltrained. So why would one of them – rather, one of “us” do something like that.
§ All food for thought….
• That concluded the call. It was 30 minutes in length. Next call is Tuesday, May 27th, at 11:30am Eastern time. Thank you for your participation. Please let other Safety Officers know of the opportunity to join the call or to access these meeting notes.
• The call started with Walter Kraujalis acknowledging that the FSF/NBAA Business Aviation Safety Seminar (BASS) was held last week. One important event out of this was that FSF released their new Duty/Rest Guidelines for Business Aviation. This is available as a free download from the FSF or NBAA websites, or at the AeronomX website at http://www.aeronomx.com/downloads.html. The significant point to mention is that the values shown in the updated duty/rest guidelines tables remain fully consistent with current scientific knowledge and operational experience (that is, maximum number of flight/duty hours and minimum rest hours and intervals).
• Mark brought up an issue. He is the safety Officer of his department. They have 3 planes, 8 pilots, and 4 mechanics. Last year they went through their second Stage 3 audit, so they have been operating with an SMS for around 8 years now. His issue is that they are not getting that many hazard reports any more. Only 2 or 3 of the guys are the ones that fill out reports. The SMS has developed a healthy dialog about issues, but after having talked about it no one bothers to fill out a report. He thinks there might be a cultural issue, the older guys will be retiring soon and are just not interested any more. How does he get folks to continue to report?
o Ron responded to say it was the same for their operation in the beginning. We do not have an SMS as old as Mark’s. The Safety Officer needs to lead by example and regularly report. Department management must completely believe in and respect that there be no repercussions for reporting or for what happened in the report. About 20% of our reports are anonymously submitted. We have had everything reported from bee’s nests to engine covers still on for start-up. Nothing bad should happen to the reporter, no punishment – nor should this information be used against the reporter when it comes to raises, promotions, or layoffs. We understand that even with modest-sized departments, that you can figure out who the reporter is even when submitted anonymously.
o Mark agreed with Ron. He also thought maybe his guys are just lazy. The guys just don’t want to do the work of filling out the report. When an event does happen, we talk about it, but we just don’t follow up with a report.
o Walter Kraujalis responded to say that what’s most important about hazard report is getting the information, that the event is reported. It doesn’t really matter who fills out the report. I urge Safety Officers to tell their folks that you will take a hazard report in any form, either as a formal written report, or notes scribbled on a cocktail napkin, or come into my office and whisper it to me. The safety officer can be the person that fills out the actual report. Sure, you might not get all of the exact facts involved, but at least you know that something happened that you might not have known about otherwise. I think it’s great that Mark’s guys are talking about the event. Mark can write the report. Be sure, though, to not just “talk about it” but to discuss the possible root causes and come up with remedial actions.
o Ray said they scrub their hazard reports and do not even ask for the date of the event. The actual date really doesn’t matter, if that helps anonymity. Just the event is reported.
o Mark said that they do the same. No dates used, just the event. We need to know some other information if it helps to understand what happened, like the location.
o Mike asked a question of Mark. Did they fill out FRATs, and if they did, is a FRAT completed for each flight?
o Mark responded that they do perform a FRAT for each flight, however, these are not written down, just discussed. They no longer record the FRATs because one of the company’s lawyers said to not keep a record of these.
o Mike said that things can start slowly. They required that a FRAT be filled out for each flight and these weren’t getting done at first. But you need to keep pressing for them to get done, it needs to become routine. …Then Mike said that sometimes compensation helps in getting reports completed.
o Mark responded to say they have used financial incentives in the past to get people to report, such as giving a gas card for a report, or at the end of their performance evaluation.
o Walter Kraujalis commented here with two thoughts.
§ First, the drop off in reporting after 8 years may be a normal progression. If you can picture a graph that shows number of reports over time, as you first start out with an SMS, there are few reports. Then as people get to better understand the SMS, and believe there is a just culture and one will not get punished for reporting, the number of reports increases. And for a couple of years as folks are into it, you may have a great number of reports. But then ultimately over time, as hazards are being identified and mitigated, the operation is going to improve and be encountering fewer risks. So naturally the number of reports will fall off. I mean, how long can a flight department continue to be screwed-up? J Sure, new hazards come along, or old ones that might have been forgotten, these need to be reported.
§ The second point is that complacency is a genuine hazard in itself to flight departments. Professionals in aviation need to remain vigilant at all times. Do you really think of the engine quitting on your next takeoff? Maybe your threshold of what should be reported should be lowered. You may want to consider that any event or incident that happens at any flight that wasn’t expected or planned for should be reported. It begs the question: why didn’t we know about this and plan for it? Or are we missing something in our flight planning process. The same logic can be used on for maintenance tasks.
• Mike asked Mark, what was this about, that their lawyer told them to not record their FRATs? Why? If it is not recorded for routine flights, how about for non-routine fights?
o Mark said they used to routinely fill out a FRAT for every flight. They even had a great app on their iPhone to fill one out. But we had a flight one day that had one of the company’s lawyers onboard and he saw the crew filling out and discussing the FRAT and asked them about it. We didn’t invite legal into all of this. We were later told by legal to no longer fill out the FRATs. We discussed this with our SMS auditors and they said they understood, and that is OK. Turns out now, we are probably getting to a point where we will begin filling out FRATs again.
o [Editor note: No comment followed this comment, but I wish to point out that there are some issues of interest regarding potential liabilities with SMS reporting. (Walter is an attorney.) They are too involved to comment briefly here. AeronomX will address this issue in more detail later, either as a topic of discussion in a future safety officer call or by setting up a special session.]
• Walter Kraujalis brought up a new question on behalf of someone who emailed in their question. They are looking at revamping their FRAT form and were wondering where they could get examples of what other flight departments are using.
o Mark said that their FRAT they use was originally from the US Coast Guard and then they tweaked it to fit their operation.
o Rick said that they started with the forms that were out there, from IS-BAO, and then modified it to address what they need to look at.
o Walter Kraujalis commented that usually you start with a stock FRAT form at first and use that for a period of time to develop it as a routine and get a feel for what it is doing for you. Then take that and make it your FRAT. The perfect FRAT form doesn’t exist that fits all types of flight operations. Some forms use numerical weighting, some use check marks and count those, or combination of these. If the FRAT form you use keeps asking about crew flight experience and this doesn’t even apply to you, then take that out. The reverse is true too. If your operation encounters a hazard on a regular basis that isn’t even listed on your FRAT, then by all means add that to the form.
o Rick said they changed their FRAT form because of practical experience. The risk of a runway is not always that it might be too short. We found that a very long runway, such as at ORD, can be a hazard and has its own set of risks. We changed the form from “mountainous airport” to “mountainous area”.
o One caller piped in to comment they like their FRAT because they have adjusted it to fit their operation. We address TEB specifically because we go there a lot. We have each pilot of a flight complete their own FRAT independently beforehand and then as part of the pre-flight briefing they compare their FRATs.
o Walter Kraujalis mentioned that to access different FRAT forms, there are a few within the SMS Toolkit from IBAC with the IS-BAO documentation. You can also Google for Flight Risk Assessment Tool and several examples come up.
§ Walter Kraujalis also offered that if everyone that is willing to share their FRAT form, to email it to me at firstname.lastname@example.org and I’d be happy to post them available as a free download from my website.
• In the last few minutes, Rich brought up a new topic. How do various flight departments handle the situation of calling the pilots during their rest period? Schedule changes and other things come up, so how do you let the pilots know without interfering with their required rest?
o Walter Kraujalis commented that this is a great question, but unfortunately there is not enough time left to properly address it. We will take it up as the first topic of discussion for the next call.
• That concluded the call. It was 30 minutes in length. Next call is Tuesday, May 13th, at 11:30am Eastern time. Thank you for your participation. Please let other Safety Officers know of the opportunity to join the call or to access these meeting notes.
• We had a question poll on the AeronomX website asking whether you used FOQA or not, and why. It has been inadvertently removed from the website, sorry. The answers after a week were 5 votes NO, and 2 votes YES.
• The call started with an issue brought up by one of the callers. James said his organization is about to go through an ARGUS Platinum audit and asked for tips as to how to handle the audit.
o Rick replied that they have been through 3 ARGUS audits. That ARGUS will go through everything. They are stricter than an FAA audit. But he recommended to “stick to your guns” as to how you do things – you don’t have to change your process just because the auditor may want it done another way.
o Walter replied that it is important to be doing what you said you would do, as it is written in your ops manual. It’s a bit of show-and-tell. Also remember that the auditor is human and has opinions. If he challenges you on an issue, ask him where it says you are to do a particular function some particular way. Where is it written in the standards. Speak in terms as to whether the task is being completed, the process is “effective”. Sometimes the auditor may only be talking about his opinion to make it more “efficient”.
o Tom mentioned that the auditor should be discussing industry best practices, not a procedure that is just his opinion.
• New topic brought up by Walter Kraujalis. Here is something I’ve been saying for some time now. Let’s take “Safety” out of Safety Management Systems. You heard me right, let’s take safety out of SMS. Now that I have your attention, my point is that the term “Safety” is a rather powerful and emotional term in our industry, and when it comes to working with safety in an SMS environment, using the word Safety can get in the way. People may be reluctant to change or improve their processes because it implies that if we make a change, does that mean what they are doing now was “unsafe”? Or another way of saying this: Some think, we aren’t “unsafe” now, so why change? But if we substitute the word “Safety” with “Quality”, it is easier to understand and accept how an SMS works. In fact, the SMS framework is exactly the same as all the quality improvement programs out there, such as TQM and Six Sigma. Maybe start thinking of SMS in terms of improving quality. I try to avoid using the word “safe” or “safety” any more – what does it mean – it can mean different things to different people. Rather, I use the term “identify hazards and mitigate risks” whenever I mean to say “Safety”. …Thoughts?
o Mike replied to say that they call their SMS a “Risk Management System”, to purposely avoid the word “Safety”. This program name also fits better with corporate headquarters because that is how they refer to similar programs within the company.
o Mike continued to say that their dispatcher comes up with a “risk value” for the day. It depends on weather, the length of day, etc.
o Drew mentioned that they use the term “risk” in their department too. They mandate the use of a FRAT for every flight. They use ARINC Direct for flight planning and then the FRAT process associated with the flight plan. They rank issues as a 1,2, or a 3, or as low, medium, or high. If the total risk comes to a 2 or a 3, the ops team knows about the higher risk and will mitigate.
o Mike said that they avoid using a number score. They just use “low, medium, or high”. If a particular operation is identified, they mitigate. He used the example that if the weather at one of their destinations will likely result in needing aircraft de-icing, they make sure to build more time into the schedule to allow for that.
o Another Mike replied to say that risks are scalable – they could be something simple or very complex like an accident. They use a blog site to identify risks. No numbers are used, just high, medium, or low risk rankings. This keeps it more subjective, to get into shades of grey, things aren’t always just black and white. Twice a month they hold an “all hands” call, in which the risk assessments for the past two weeks are discussed and dealt with. They also sanitize, or de-identify, their reports.
o Rick said they do a FRAT for each leg. They message to the dispatcher and charter broker what the risk value is for each FRAT. Fi they see any high numbers, then management can step in and question a specific flight.
o Tom said they use debriefings after a flight as a risk evaluation tool. They compare what the FRAT forecasted the flight was supposed to be, to what actually happened on the flight. Things change and it is important to understand why they change. This information helps with being more accurate with future FRATs.
§ Walter Kraujalis said he like this idea. One gauge to use as to what is a reportable event, is anything that happened that was unplanned or unexpected should be reported. It is important to understand why it was unexpected or not planned for.
o Liz said they use the FRAT for briefing before each flight.
§ Tom said try using that same process for post-flight. This is also a way to get pilots involved in the SMS.
§ Rick mentioned that the Coast Guard Auxiliary using a pre-mission evaluation that is communicated to mission headquarters.
• Liz brought up a new topic. She asked how many operators were using FOQA? She thought the cost was prohibitive and wanted to know people’s opinion as to the value from FOQA.
o Drew said that they are a Part 91 operator but have their aircraft available for charter under a partnering vendor’s 135 certificate. The charter operator has been going through a tremendous growth spurt with adding a lot of aircraft and new pilots. They decided that they wanted to use FOQA to be used to assess and train their pilots, as well as enforce standardization. He said the data feedback from FOQA for them has been helpful, but not really all that enlightening for them. Their 91 operation is a close-knit group and only have their planes on the charter certificate for revenue purposes. He guessed that the value of the FOQA data feedback would depend upon the type of operation. For the charter operator, it has been very helpful. For his 91 operation, not so much. He said that if it were just for them to decide for their own operation, they would probably not bother with FOQA.
o Walter Kraujalis gave a brief background on FOQA for those on the call that may not be familiar with FOQA. He said that is clearly more beneficial for the larger organizations. As you get smaller, it becomes harder to justify the cost for the value. He also suggested that there are cheaper alternatives becoming available, that are like FOQA in providing feedback for standardization and training. He mentioned that with his safety engineering relationship with Allianz aviation insurance, they are keen on the Appareo Vision 1000 (see http://www.appareo.com/primarymenu/products/alerts-flight-data-monitoring/appareovision-1000/). It is being used by flight schools and now helicopter EMS operators, to capture flight and cockpit data for tracking purposes. He feels this same or similar system could be used in business aircraft. Sure there is the issue of a camera in the cockpit, but aren’t we to the point in our industry that we are all professionals and having a camera in the cockpit is soon to be expected. Maybe just have it on for the 20 minutes of takeoff and climb and 20 minutes of descent and landing. There can be a process of sanitizing the information.
§ One caller responded that it is important what is being done with the data from such a device. Management needs to understand the privacy issues. One wouldn’t want it used for disciplinary actions.
• Walter agreed. But that is the very idea behind a “just culture”. Management, and/or the safety management staff, understands that if something happens to any one of our pilots, it could happen to any of us.
• That concluded the call. It was 30 minutes in length. Next call is Tuesday, April 22nd, at 11:30am Eastern time. Thank you for your participation. Please let other Safety Officers know of the opportunity to join the call or to access these meeting notes.
• This was an interesting question about how many folks are using FOQA. I have posted a question poll on the AeronomX website at http://www.aeronomx.com/safety-officerteleconferences.html. Please try to go there in the next two weeks and give your simple “yes” or “no” answer. Try also to leave a quick comment as to why you do or do not use it. I will give the results of the poll in a future conference call.
• The call started with an issue brought up by one of the callers. The caller said that they are a small flight department with one Challenger and four pilots. He found it hard to get folks to participate and stay motivated with the SMS. He felt that it was related to the idea that the SMS made more work for people. He said that it is hard to get people to write things up. They went through a recent audit and the auditor suggested that they consider giving a “prize” or reward to those that submitted reports – but he doesn’t want to do that. His question was, how to get people involved and continued to be motivated, to participate in an SMS. Especially for a small flight department.
o A caller responded that the personnel need to see that the SMS is being effective. She asked the other caller what was their documentation process.
o The first caller responded that reports do get written and the results are shared with everyone within the department. He continued with an example of one of their reports about a charter passenger bringing a wild animal onboard that got loose during the flight.
o Another caller said they have a similar issue. They found that if everything within the SMS was simplified, it is more likely to be used. They use their reporting process not only to identify hazards, but also to include ideas for improvement. He gave an example of how the process was used to report that a Wall Street Journal was not onboard for a particular flight.
o Walter Kraujalis commented that he agreed that a simple SMS is best for smaller flight departments, and to include ideas for improvements. However, to use it for reporting a newspaper was missing is somewhat diluting the reporting process’s core purpose of dealing with hazards.
• A caller brought up a new issue. He asked what anyone thought about having the aviation manager or chief pilot as the safety officer. Did that affect the SMS?
o A caller responded to say that their chief pilot was the safety officer and everything was fine.
o Another caller said that he would not want the boss to be the safety officer. If he were, it would short-circuit the SMS process. He wanted to have the process of root cause analysis and come up with recommendations from those within the safety committee.
o Another caller said their Director of Operations was the safety officer and that it works.
o Walter Kraujalis commented that management still runs the department. The SMS process is somewhat the “eyes and ears” for management, to provide feedback as to whether their processes are working or not, or need to be modified. It is difficult at times, especially in a small flight department, to have a separate person performing the role as safety officer. Not just anyone can be the safety officer – there has to be competence and also cooperation between the safety officer and management. The SMS process offers up recommendations to management, not mandates. Management still decides whatever action should be taken, hopefully with the counsel and advice of the SMS process. If the manager is the safety officer, that person hopefully is open to listen, open to discuss that things may not be perfect, and open to change.
• Another caller pointed out that it is all about culture. Management has to believe in the SMS process. An SMS needs to have the support from the top or it will never work. Also, the Safety Officer needs to have training in safety theory and SMS management. o Another caller asked what training programs were out there available and what would be the recommended minimum training.
o A caller responded that there is the IBAC course, and NBAA has PDP courses. The caller later emailed to AeronomX some course information:
§ USC Viterbi safety and security program: http://viterbi.usc.edu/aviation/aviation_cert_programs/aviation_safety_securit y.htm
§ Bombardier Safety Stand-down
§ NBAA PDP
§ IBAC-fundamentals of IS-BAO workshops
§ ERAU safety certification o Other callers mentioned the Embry-Riddle safety program.
• A caller brought the discussion back to the notion that SMS is an advisory role and not telling management what to do.
o A caller responded there are two relative points. First, management sets the culture. The Director of Aviation needs to believe in identifying issues and hazards. The manager need to encourage full reporting – and understand that it may be a cultural change for people to start reporting. Second, the manager sets the tone. He needs to let people know that he is willing to listen and discuss what could be done better. He has to agree to the process of change. Plus, the safety officer needs training to be effective in their role.
• That concluded the call. It was 30 minutes in length. Next call is Tuesday, April 8th, at 11:30am Eastern time. Thank you for your participation. Please let other Safety Officers know of the opportunity to join the call or to access these meeting notes.
• No caller had a topic to start with so the first topic brought up by Walter for discussion was the lack of root cause analysis (“RCA”) that he is seeing in some of his audits. It is common to just treat the “effect” or “symptom” of a reported problem and not dig down into what the possible underlying hazard that is the “cause” that ultimately made the problem happen.
• There are several techniques published that offer a way to do a RCA. Some techniques are proprietary to a particular vendor that sells it as a class or service.
o In the IS-BAO SMS Tool Kit there is the SMS Guidance Manual that discusses RCA briefly.
o The FAA has a Quick Reference Guide at http://www.faa.gov/about/office_org/headquarters_offices/avs/offices/afs/afs900/sms/ media/newsletter/sms_qr_guide.pdf.
o Another great publication is the ICAO Safety Management Manual at http://www.skybrary.aero/bookshelf/books/644.pdf.
• One of the simplest methods is called the “Five Whys” in which the analyzer keeps asking the question “Why did that happen?” going down to five levels of possibilities. More about this can be read at http://en.wikipedia.org/wiki/5_Whys.
o Walter used the example of one operator that upon preflight, they found the aircraft battery dead. They were able to fix the situation before departure, but a hazard report was written. Using the five whys:
§ Why was the battery dead? Because the aft equipment bay utility light was left on.
§ Why was the light left on? Because an AMT was back there working and forgot to turn the switch off.
§ Why did the AMT forget to turn the light switch off? Because he was interrupted from what he was doing and left in a hurry.
§ Why was he interrupted? Because he was needed to work on another aircraft that had a problem right then.
§ So just after 4 whys, it is found that one of the possible underlying issues was a work interruption situation. It is better to deal with that problem, which could have manifested itself in many other ways than just the battery being dead.
• One caller said that with RCA analysis could be relatively easy when there is an easy way to fix the problem, to assess the blame. But if one keeps drilling down into the RCA, it can reveal an organizational issue, such as lack of staffing, that is difficult to bring up to management.
• Another caller mentioned the RCA technique called HFACS. He provided the following additional information following the call:
o Dr. Wiegmann and Dr. Shappell developed the program for the Navy and Marine Corps - it is now adopted DoD-wide: https://www.nifc.gov/fireInfo/fireInfo_documents/humanfactors_classAnly.pdf
o Dan McCune - Safety Chief at ERAU does a good job with a 2-day course. Here is the link to the workshops: http://hfacs.com/
• Another called brought up the topic of safety communication, and asked the other callers what some of the ways they use to get safety messages out to the employees. He said they use a computer drive that has a “read and initial” process whereby the reader has to acknowledge that they have read the message.
o Several callers expressed that they either use an online process similar to what was just described, or use email with a read receipt sent back to the sender.
o One caller mentioned that an email read receipt return is not necessarily proof that the receiver actually read the message.
o Another caller mentioned that it is probably best to follow up at the next department meeting to reemphasize the safety messages that have been emailed since the last meeting. It is also good to be sensitive to the importance of the information that is going out. If it is very important, it is probably best to not just trust emailing it out, but rather to call or meet with each member of the flight department to make sure they have received and understood the message.
• Another caller brought up the issue related to interruption to routine. He said that when someone is made to change from their routine due to circumstances, like the hurry associated with a pop-up trip. They had an experience that due to a hurry-up situation, the FMS was not programed properly and it wasn’t caught until a normal routine check to see that the programed Vspeeds on each side did not match. Not only was this not good, it could have been worse with the fuel programming.
o Another comment was shared that that is the reason to have checklists. Need to make sure one is not so complacent with checklists.
o There was another comment about complacency. It is an issue of culture and the work environment.
• That concluded the call. It was 30 minutes in length. Next call is Tuesday, March 25th, at 11:30am Eastern time. Thank you for your participation. Please let other Safety Officers know of the opportunity to join the call or to access these meeting notes.
The first topic discussed was from a presentation that Walter gave at the HAI Helicopter Convention called “The Best Safety Device is a Good Manager” (a copy of slides available for download from the AeronomX website. What does a Safety Officer do if he or she has a flight department manager that is not fully supportive, or worse yet, opposed to safety management efforts?
o One caller said that his Chief Pilot submitted a hazard report on which he also wrote the suggested solution to what happened. When the Safety Officer and Safety Committee received the report for analysis, they were of the opinion that to implement the suggestion the Chief Pilot provided would have increased risk to the hazard, not reduce it, so the Safety Committee did not want to make it their recommendation but rather mitigate it with a different solution. The Chief Pilot disagreed with their recommendation and wanted to implement his suggestion. What followed was 18 months of a stand-off between them, only to be ultimately resolved when the Chief Pilot retired. It was an awkward and uncomfortable situation.
§ Walter added a comment here to say it is important that the Safety Officer himself be objective about the issue and not subjective, in other words is the Safety Officer thinking clearly himself, that this is a real issue and others agree, or does only he think it is important and maybe it really isn’t. The goal for most SMS is to lower risk to the lowest acceptable level as practical. Who decides where is the risk becomes acceptable? That is up to company management, in their opinion as to what it takes to get the job done.
• [To expand my explanation somewhat that I did not say on the call.] Situations may come along that folks disagree where that level is, in fact, an individual pilot may have a personal level of acceptable risk that is lower than what the company is will to accept. An easy example to understand this is a company that does low-level powerline patrol in a light single-engine piston aircraft. The company must fly low enough for the observer to see enough detail and the economics of the situation allow only the use of the cheaper to operate ASEL airplane. There is the hazard of single engine and low level flight. The company accepts that risk with whatever mitigation means they use. What if the safety committee there comes up with the recommendation that they should use a King Air flying at 3,000 feet and with a high-resolution gps/laser directed turret-mounted camera for patrols? Does management have to accept that? Based on economics it might not work and drive the company out of business. Rather, if you are a pilot flying for that company, it is expected that the risks of the mission are an acceptable risk to you too. If not, you shouldn’t work there. Using this example and applying it to the situation above, though not all the facts of the situation are given, it is up to the chief pilot to ultimately the lowest level of risk practical. However, if the chief pilot is flat out wrong, misguided, or doesn’t truly understand the risks, or is well outside the normal boundaries of industry practices, then I think the Safety Officer/Safety Committee is obligated to push on the issue. That is what the dotted-line on the organizational chart from the Safety Officer to the Accountable Executive is there for. It might be a “you bet your job” situation, but that is why it is there. Pick your battles. If it truly is an unacceptable risk, use the dotted-line if all attempts to reason with the Chief Pilot have failed.
o Another caller said that his Chief Pilot was rather controlling in that only he was allowed to talk to the Accountable Executive about flight department issues. The AE was a regular passenger on the plane and the Safety Officer was one of the pilots and therefore could talk with the Accountable Executive about things related to that specific flight. But the Chief Pilot would get upset if the Safety Officer talked about flight department safety issues with the Executive.
o Another caller said his relationship with the Chief Pilot was good, but on several occasions on trips that the Chief Pilot was the PIC, he would want to bend the rules for himself. On one occasion he wanted to extend the duty hours because he thought it was OK for himself. The caller said that as the Safety Officer he approached the Chief Pilot to point out to him that he is setting an example for the whole department if he doesn’t follow the ops manual limits himself. The caller continued to say that the trend and the culture of the flight department is set by what the boss does. In this specific instance, the Chief Pilot agreed and a third pilot was added to the flight.
• A caller brought up a new topic. What should the flight department do when implementing an SMS, it is turns out that the department should no longer be doing something it has been doing for years? What if there has been an unsafe practice going on and they want to change, BUT it touches upon a point that affects service. The example given was this operator did not really know or do much about abiding to zero fuel weight limitations for the aircraft. They would regularly fill all the seats of the aircraft, which turned out to be beyond the zero fuel weight limitations of the aircraft. After implementing the SMS, this issue was brought up. The analysis was clear that they should be following the OEM limitation of the aircraft and that regularly exceeding the ZFW has probably put additional stress on the airframe. They no longer wanted to ignore the ZFW limitation, but that meant they had to tell corporate management they could no longer go with all 7 passenger seats filled, but rather with only 6 passengers. Awkward moment. So how does one explain to the boss that they cannot take that 7th passenger any more? When the boss asks why, are you really going to say that what we’ve been doing for years has been wrong and unsafe? What is the boss going to think? Obviously not something good.
o Several callers added a couple more similar stories of Sabres without de-icing capability flying into known icing conditions, and Lears exceeding limits.
o One caller responded to say that this is why when implementing an SMS it is important to do so with the understanding and acceptance by corporate management. Tell management that by implementing an SMS, it will likely result in changing some of the processes and procedures, even those we have been doing for years. And that changing our procedures might affect service. Emphasis to management that by implementing an SMS adds value to the operation and includes best practices.
o This same caller continued to say that in his experience, that the development and implementation of an SMS is usually associated with a change of flight department management. Prior flight department management was allowing bad practices to continue. He said that he didn’t want to necessarily throw the prior chief pilot under the bus, but hey, the truth is the truth.
o Walter commented: I don’t know the silver bullet answer that works every time for this situation. I agree that you should set the expectations of management that things might change when an SMS is implemented. I absolutely would not want a flight department to continue with a bad practice just because they are afraid to change if they had to explain why – that they have been wrong/unsafe all these years. Yes, this may be a situation where you have to “man up” and do the right thing no matter the consequences. But then again, don’t be too harsh on yourself. If we consider ourselves professionals, and have been given the proper training, and don’t have suicidal tendencies, then we should really ask ourselves what is the root cause of why it was the way it was? Was it complacency? Was it a somewhat acceptable practice at one time? Was it because of organizational dynamics that change did not come sooner? That is truly what needs to be corrected.
• Another caller said that to implement an SMS as part of IS-BAO, and to not take it to heart and follow SMS principles, just means one has created a lot a paperwork for nothing. There needs to be buy-in by management and everyone in the department.
o Another commented that be aware that to everyone comes to understand and accept SMS practices it at their own pace. It takes a constant reassurance and encouragement.
• That concluded the call. It was 35 minutes in length. Next call is Tuesday, March 11th, at 11:30am Eastern time. Thank you for your participation. Please let other Safety Officers know of the opportunity to join the call or to access these meeting notes.
The first topic discussed was the new 2014 IS-BAO protocol and audit report form. It and the revised Standards are available for download from the IBAC website. The question concerned how the new Form 8.2 within the Chapter 3 SMS section, has some new questions about Appropriateness and Effectiveness, which are marked with blue and green highlighting. Is this something that the operator fills out or the auditor fills out? On the call, Walter answered that these are questions that came from the old Form 8.1 SMS evaluation matrix and will normally be filled out by the auditor.
The next topic concerned Hazard Reports. Or some operators may call it something else such as Safety Reports or similar. The question is, in regards to an SMS, how many is an appropriate number of hazard reports that should be reported in a given year? To start with, is there a meaning to what the number is? Yes, from two standpoints: 1st is from identifying hazards, the 2nd is getting buy-in and participation from your employees into the SMS. There is one clearly wrong answer, and that is zero reports. It indicates no participation. As to how many above zero is subject to the size and complexity of the flight department. Walter offered an opinion, as a point of reference, he uses the number of employees in the department should equal the number of reports in a year. For example, if you have 7 pilots, 2 mechanics, and 2 staff members, for a total of 11 employees, you should average a minimum of around 11 hazard reports a year. Sure some employees will fill out 2 or 3 and other will fill out none, but the average should work out. Of course there is going to be variations from company to company, but basically Walter is of the opinion, that as vigilant aviation professionals, we should be able to spot/experience and report at least one hazardous situation in a year. Walter has even seen some operators make it a requirement for employees to file a report each year, or each quarter, or even each month. This is meant to keep everyone vigilant and participating into the SMS. The counter-argument is that people might fill out frivolous reports.
Feed back from the callers included these comments:
A related question was asked: How do you motivate employees to fill out Hazard Reports. Comments to this questions were:
One caller mentioned that they are working on one area to improve their SMS and wanted to know if anyone else was doing something similar. What they are doing is when a Hazard Report comes in, their Safety Committee will give it an initial risk score from the risk matrix. They then analyze the cause, come up with a corrective action and implement. The new thing they are trying is to have a different group of individuals, ones other than the ones who did the initial scoring, then give the situation a new risk score from the matrix, to see if the mitigation is being effective. No one stated they were doing something similar, but comments were made that it sounded like a good idea.
One commentator mentioned that they are not really happy with the online SMS service that they have and was asking if anyone knows of an online SMS service that is perfect. Here are some of the responding comments:
That concluded the call. It was 30 minutes in length. Next call is Tuesday, February 25th, at 11:30am Eastern time. Thank you for your participation. Please let other Safety Officers know of the opportunity to join the call or to access these meeting notes. Thank you.
This was the inaugural teleconference sponsored by AeronomX providing a convenient and easy venue for flight department Safety Officers to meet and discuss issues they are encountering with Safety Management. Here are the notes from the meeting. It is difficult to get into much detail as to what was discussed about each issue, so you are encouraged to join in on the next calls.