Safety Officer Teleconference (7)

• 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 [email protected] 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.