AEROSPACE Sharing safety lessons

It’s good to talk​

Aviation consultant, DR HAZEL COURTENEY FRAeS, considers the value of communication across the aerospace industry.

NATS​

Aviation is full of highly specialised professional groups: pilots, engineers, air traffic controllers (ATCOs) and more. Within those groups are subgroups of specialists with deep knowledge of their part of the aviation system. We rarely go outside of our groups because usually the issues we have are deep and narrow. We huddle together with our fellow aerodynamicists or biplane pilots, discuss the finer points of whatever it is, and we come out with a way forward. Generally, this works very well. For safety issues, there are some occasions where the ‘narrow specialisation’ path is not enough and can benefit from an additional approach. That is, to bring different disciplines to the table.

Who does this?​

Safety management systems bring together some of the different areas within an organisation to discuss safety. This is a good start, but the best safety solutions may go wider.

The EASA European Plan for Aviation Safety, the ICAO Global Aviation Safety Plan and the ‘Significant Seven’ campaign promoted by UK CAA some years ago, study the main types of aircraft accidents and explore the key contributions from all disciplines that could help to reduce that risk. What arises as an operational problem may have contributions from many different areas. Or, the problem may manifest in one area but the best solution may possibly come from a different area.

STUBBORN OPERATIONAL SAFETY ISSUES CAN REALLY BENEFIT FROM GETTING INDIVIDUALS FROM ALL DISCIPLINES AROUND THE TABLE TO SEARCH OUT WHERE THERE CAN BE IMPROVEMENTS OR HOW THE PROBLEM CAN BE SOLVED

Loss of control in flight can involve pilot training, aircraft design and maintenance and weather forecasts for route planning.

Controlled flight into terrain (CFIT) accidents were once the most common type of fatal accident. CFIT is an operational accident with operational causes, yet the most effective risk reduction came from aircraft technology with terrain avoidance warning systems, such as the enhanced ground proximity warning system which has almost completely stopped these accidents in aircraft that carry the system.

Runway excursions, where an aircraft leaves a runway surface, happen rarely but when they do, they often occur due to unstabilised approaches and thus often have serious consequences. This can involve almost every part of the system, including airport design, precision approach technology, airspace and approach design, airport ground services, aircraft system design, documentation design, aircraft maintenance, air traffic control, pilot training and procedures, and the interfaces between these areas. An airport includes runway length, width and slope, airport layout, runway surface condition, runway end safety area (or lack of it) or arrestor bed, location of nearby obstacles or hazards like water, roads or buildings, fire and emergency services. Does the airport have the benefits of precision approach technology, is there a circling approach for noise abatement, is the runway kept free of debris, wildlife and contamination and is the surface friction measured and communicated to pilots as necessary and is the windsock prominent and visible during the approach and take-off (for all runways) to confirm surface wind?

Runway Incursions, where an aircraft or vehicle enters an active runway without permission from ATC to do so, can have contributory factors relating to airport signage, vehicle driver training, ATC phraseology, pilot distraction, CRM training, or possibly multiple MELs which are all ‘legal’ but cumulatively may take the attention of the pilot who could miss an ATC instruction while rebooting an aircon pack. Mitigations could lie in changes in any of these areas – or it could be installation of runway stop bars or ground radar whose absence is not a contributory cause but whose addition might be a decisive asset.

Airborne conflict is a combination of operational, ATC and airspace issues but the traffic collision avoidance system is another aircraft-based technology intervention that significantly reduced the risk. If the problem is operational the solution could be operational but it does not have to be.

Case study 1: Pilots and ATCOs 

UK pilots reported some issues during arrivals on a long-haul route. After a long flight, they would get close to the airport in darkness but with their arrival well planned. Then ATC would take them off plan with vectors and they may be unable to follow local radio chatter. This could be unsettling as they awaited new landing instructions. As part of the State Safety Programme, the relevant authorities were asked for a meeting to discuss possible solutions. The request for a workshop between the visiting pilots and the local air traffic controllers was initially dismissed. The first reaction was that this was covered at the regular management meetings between the airlines and the air traffic service, where events were resolved individually. Soon they realised that they were not being criticised but were being invited to use their insights to help solve the root of the problem. They agreed to help. A workshop bought the ATCOs and pilots around the table to discuss the issues and find a solution. Within one day, the problem was resolved. The ATCOs agreed to let the incoming pilots stick to their plan and the pilots agreed they would not complain about the potential five minutes delay that this could create for their arrival time. This reduced the pilot concerns dramatically. One of the pilots involved said, ‘We’d been exchanging management emails for a long time and not made much progress on this. Meeting with the air traffic controllers in person made it so much easier to discuss the real nature of the problem and explain how it actually feels for us, the pilots. They could quickly see a better solution and since their supervisor was there as well, they could agree to implement it.’ 

Case study 2: Pilots and ATCOs

As part of the UK State Safety Programme, the UK CAA noticed a relatively high level of occurrences in UK airspace involving airlines from Turkey, over a five-year period. After contacting the Turkish DGCA, they agreed to work together in a Safety Partnership. Aysin Zeren and Gaye Dogan of DGAC Turkey visited the CAA and proposed a workshop between UK ATCOs and the Turkish pilots. The workshop was held in Istanbul with the UKCAA, the Turkish DGAC, several UK NATS ATCOs and pilots from all four of the airlines in Turkey who fly to the UK. Both ATCOs and pilots made presentations about the situation from their point of view. We had lunch together and got to know each other as people. Then the pilots and ATCOs sat together to identify what actions there should be to improve the situation. From this discussion came actions for all parties in both countries and agreement to meet regularly to track progress. Haydar Yalcin, Deputy Director of DGCA Turkey provided strong encouragement for airlines implementing the workshop actions to make sure the partnership was effective. The result was a dramatic reduction in safety events which fell to zero by the end of the year – outperforming all other airlines for the same time period! Karen Bolton, Head of Future Safety at NATS said ‘air traffic control relies on good communication between pilots and ATCOs. Bringing them together helped us all to understand what was really causing the issues and how to improve our performance.’ In one discussion about a non-standard UK procedure, a frustrated ATCO said ‘but you fly to London every day!’ to which the pilot replied ‘No. My airline flies there every day. I fly there once a year.’

Benefits​

Airbus

Aviation benefits from great expertise of individuals and specialised disciplines and most issues can be resolved within those areas. However, stubborn operational safety issues can really benefit from getting individuals from all disciplines around the table to search out where there can be improvements or how the problem can be solved. There are other benefits, too. It stops the conversation going down blind alleys saying ‘there’s nothing we can do about that, that’s down to the airport/ATC/engineering’ because those people are all in the room. It also helps avoid solutions to an issue having unintended consequences for someone else. Sometimes, specialists believe that a certain aspect is dealt with by another area but, when they discuss it together, they may discover it is not covered as they thought.

Working in this way means that we get to know each other as people. When issues arise, we can call upon a friendly face for an informal perspective from another discipline. It can be harder to go through a management chain before really knowing how another area might see the question or be able to contribute.

Resilience in organisations and transport services is currently very topical. Personal relationships across different functions of the organisation is a great asset for resilience because it promotes understanding and real co-operation. It helps people to learn the language and thought process of others and, because they have become friends, they want to help each other find solutions rather than just batting off the problem to another department.

Case study 3: Design engineers and maintenance engineers

Airbus

The human hazard analysis (HHA) is a tool used by aircraft design engineers to examine whether the design could be vulnerable to human error during aircraft maintenance. The focus is on human errors that are realistically plausible, and this means bringing them together with the aircraft maintenance engineers to discuss the design features. This is already done in some fixed wing manufacturers. It is now being trialled in helicopters by HeliOffshore, who have now organised three successful workshops with design engineers and maintenance engineers working together to trial the process on safety critical tasks (see AEROSPACE, March 2019). Scott Carmichael, Project Manager at HeliOffshore said ‘Bringing maintenance engineers together with design engineers produces great insight for both teams but most of all the conversation between them produces a better solution than either team could implement on their own.’

Case study 4: ATC, avionics manufacturers and GA pilots

AirspaceAware​​Occasionally, light aircraft stray into controlled airspace and this kind of infringement can be a headache for ATC. When NATS were looking for ways to reduce infringements, they created new technology for monitoring and even had dedicated ATCOs on busy weekends to look out for potential problems. However, more was needed. NATS is an ATC organisation but they recognised that another way to reduce infringement risk was to get helpful technology to the light aircraft pilots. So, they worked with avionic manufacturers to create the Airbox Aware airspace alerting tool (right) and the SkyDemon Light flight planner to help the pilots of light aircraft stay out of controlled airspace. Jonathan Smith at NATS said: ‘This is not the normal business of an ATC organisation but for an effective solution it was important to reach out to light aircraft pilots and commercial avionic manufacturers. We found a commercial arrangement that was beneficial for everyone involved.’

Conclusions​ 

Aviation specialisations are complex and it can be tempting to keep ourselves within our closed communities and talk our special language to each other. It feels comfortable to talk with others who understand our well-developed technical viewpoint and we feel we make progress quicker – at least in the short term. The next level of gains in aviation may come from taking the time to understand each other and finding ways to leverage the power of the overall system. ‘It’s good to talk’! 

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