Perhaps the abrupt maneuver was due to the raptor seeing a more desirable fish or a menacing shark; perhaps it was a reaction to a last second change in the prey’s position.  Regardless of the reason, instead of ending with an elegant talon-grab, the modified approach resulted in a spectacular semi-controlled crash into the water.  After impact, the stunned osprey paused momentarily to gather his senses, then slowly flapped his wings, struggled free of the water, and took flight while letting out some pained squawks of avian profanity, reflecting no doubt his confused mental state.

Any pilot with imagination can hear the osprey flying away saying to himself, “Well, that approached sucked!  What the heck happened?  Everything was looking good and then suddenly, crash.  Damn lucky I could fly away from it.  I really need to stick to stabilized approaches or go around!”  We doubt the Osprey Safety Community convened a mishap investigation board, submitted an anonymous pilot error report, or held a safety standdown; but it is likely that the osprey himself learned from the incident.  If not, the future bodes ill for his survival, because the mortality rate of young raptors is very high, and only the fittest and best adapted survive.

Scientists are just starting to uncover the realm of animal cognition, and in a few years perhaps we will have a better idea of the extent to which animals such as ospreys “think” in such situations; how much they learn form their mistakes.  However, anyone who has observed household pets carefully knows that animals can learn from experience.  And those that don’t can pay a steep price.  For example, indoor-outdoor cats residing in houses next to busy streets must learn how to cross a road without being run over.  Some are successful, others are not.  And for the ones that survive, success is clearly more than a mere matter of luck.

Consider now the story of a human rather than an avian angler.  Near the beach where the osprey crashed into the sea there is a drawbridge—popular with fishermen—that spans the inland waterway.  Close above the bridge and parallel to it, an electrical power line runs from the mainland power generating station across the waterway to the beachside barrier island.  For most of its length the power line is 40 feet or more above the low-lying bridge.  Where the bridge rises toward its draw above the waterway channel, however, the distance between the bridge walkway and the power line diminishes to about 10-12 feet, providing a significant hazard for fisherman casting lines from the rise of the draw into the deep waters of the channel.  And, of course, fishermen prefer to fish from the draw rather from the lower bridge, because the channel is where the big fish lie in wait.

The power line in the area of the bridge’s draw is covered with bobbers, hooks, lures, sinkers, bits and pieces of line—the detritus of countless miscasts.  In one sense it is a small yet notable monument to human fallibility and to the repetitive nature of error.  Imagine the next fisherman, Billy Bob Dumcaster, to challenge the power line.  Prepping his gear to catch a trophy fish from atop the draw, he says to his fishing buddy, “Look at all them lures up there.  Man, I wish I could get up there and cut me some down for my tackle box.”  Moments later, Billy Bob casts his line and yells out, “Oh crap, man, I just got caught up in the power line!  I can’t believe it.  What luck!”  The situation illustrates perfectly the wisdom of an ancient proverb: “Everything that happens once can never happen again.  But everything that happens twice will surely happen a third time.”  Billy Bob’s problem with the power lines wasn’t a matter of bad luck.  He knew—or should have known—that a threat existed, yet he followed in the blundering footsteps of countless anglers before him who had gotten tangled up in the power line.  Moreover, Billy Bob surely will not be the last fisherman to commit such a blunder

In another sense, the power line represents not simply human frailty and folly but a challenge to human ingenuity.  Billy Bob was committed to fishing in the channel, and to do so he had to deal with the risk of the power line.  However, the mere existence of the hazard did not ensure that Billy Bob inevitably would fall victim to it.  Evidence of the hazard was right in front of his eyes.  Had Billy Bob heeded it instead of casting recklessly and instantly regretting his actions, he might have avoided becoming the power’s lines next victim.  To minimize the risk he might have decided to use a sidearm cast, thus reducing significantly the chance of entanglement.  Or if the proximity of other fishermen precluded a sidearm cast, he might have sharpened his overhead casting skills by practicing beforehand from the lower part of the bridge where the chance of getting tangled in the power line is very much smaller.  Or, failing initially to understand the meaning of the evidence hanging from the power line, Billy Bob—after he lost one lure to the threat—could have chosen to minimize the risk on his next casts by taking the same or similar risk-mitigating steps.  Perhaps he did.

The story of Billy Bob reminds us that every time our personal performance does not meet our expectations, we are presented with an opportunity for improvement.  Seizing such opportunities constitutes what has been called embracing our blunders.  Similarly, when we avoid blunders by learning from the missteps of others who have preceded us, we are embracing the blunders of others.  Some people simply dismiss missteps as examples of human fallibility, or take the cowardly position of covering up their actions or redirecting blame instead of learning from their embarrassing missteps.  It takes courage to foster improvement by actively seeking out and embracing shortfalls.  Nonetheless, we must not fail to do so. 

According to Terrence Ketter, a psychiatrist at Stanford University, complacency results when we become overly comfortable in our profession.  “The cost of happiness is complacency,” he argues; “discontent can drive change.”  Ketter does not mean, of course, that one must be unhappy to overcome complacency and to become a successful advocate and promoter of aviation safety.  Rather, he is reminding us that professional and personal routines can sometimes result in a gradual descent into comfortable mindlessnes. 

“Habit is a great deadener,” Vladimir says to Estragon in Nobel-laureate Samuel Beckett’s absurdist play, Waiting for Godot.  The deadening effect of habitual, often unconscious behavior may be more common in aviation than one wishes to acknowledge.  Consider the psychological state jokingly described by pilots as “hours of boredom” in the cockpit (with a “moment of stark terror” potentially waiting to dispel it).  Another phrase pilots use to describe a diminished state of cognition is “fat, dumb, and happy.”  This phrase aptly describes the mindset of two airline pilots who a few years ago overflew their destination by more than a hundred miles because they were—ostensibly at least—occupied on the flight deck with their laptop computers.  Randall Jarrell describes a similar state of mental sleep in his famous and shocking aviation poem, “The Death of the Ball Turret Gunner.”  Flying in a B17 Flying Fortress during a World War II bombing mission, the gunner is suddenly awakened from his childlike faith in the “State … and its dream of life” by “black flak and the nightmare fighters.”  He dies in the enemy fighter attack on the bomber, and after the crippled plane lands is “washed …out of the turret with a hose.”  The consequences of mindlessness can be severe.

Repetitive, mindless behavior is the antithesis of professionalism in aviation safety.  It is a habit of mind that is both comfortable and slothful.  Such a mindset must be arduously resisted, for it leads both by omission and commission to non-optimal thinking and the perpetration of unsafe acts that lead to accidents.  To break the mind-numbing spell of habit in aviation, we must consciously embrace the discomfort of what Ketter calls “discontent.”  We must constantly strive to recognize and analyze our errors.  In so doing, we prepare ourselves to recognize developing accident chains and to intervene before they result in tragedy.  “Embrace thy errors!”  That is truly sage advice, whether you are an osprey, a fisherman like Billy Bob, a ball turret gunner, or a professional aviator.

As a professional flight instructor with the opportunity of witnessing the baseline skill set of thousands of fellow airmen in countering loss of control in-flight events first hand, I welcome all opportunities to address this field of training. After careers with the military, the commercial airlines and nearly two decades of upset recovery-specific instructional experience, my passion for helping both educate and arm pilots with necessary knowledge and skills to enhance their air safety is not only growing but compounding month after month, year after year.

The allotted space for my words are limited so let’s use the following excerpt of a real-life icing upset-encounter to frame the discussion that follows:

“The warnings started to sound ‘bank angle, bank angle’ as we exceeded 60 degrees and my attitude indicator was rapidly turning more brown than blue. It finally flashed through my thick skull that no matter what the airspeed said we were in a full-on stall that was rapidly turning into a spin.” – US Army Fixed Wing Pilot (Full story: http://tinyurl.com/usarmy-ice-upset)

As pilots we are required to be aware of the drag penalty and lift influences of main wing icing. However what is often missed, or perhaps even skipped as a feature threat in our training as professional pilots, is the impact this type of icing can have on stall angle of attack.

Simply put, main wing icing tends to reduce the wing’s stalling angle of attack or, in strict ‘pilot speak’, reduce the critical angle of attack (AOAc). Fortunately, many advanced and commercial airplanes make a correction for calculated AOAc when anti-ice and/or de-ice systems are engaged. However, what if the icing condition is:

1      Worse than anticipated by the system’s correction,

2      Not considered (ie. no correction made) by our particular airplane’s stall warning presentations and system, or

3      Simply unnoticed (perhaps through pilot distraction, lack of attention or rapid accumulation than anticipated)?

Although not the leading cause of environmentally-induced airplane upsets, airframe icing is most certainly one of the threats to our safety that can have the ugliest presentation of all … that is; little to no stall onset warning.

How can this be so?

Whether we have a dynamic calculation of predicted AOAc through our aircraft’s on board systems or we just have a published ‘stall speed’ number firmly set in our mind’s eye, each one of the above three conditions can significantly alter the approach to stall and the aerodynamic stall’s sequence of anticipated precursor events and protections. In any of these cases, when the stall is encountered, it is often a full aerodynamic stall at or beyond AOAc and rarely ever responds favorably to the mindset of ‘thrusting out’ or ‘minimizing altitude loss’ as primary concerns. Most pilots are unaware that beyond AOAc the physics of flight are altered due to the onset of negative stability and associated atypical control responsiveness. Aggressive and correct Angle of Attack reduction as the first and most critical priority by the pilot can literally make the difference between life and death.

How about Bombardier platforms, can main wing ice be a controllability concern?

●     Skywest 3855, Bombardier CL-600 in January, 2004: http://tinyurl.com/csas8h8, excerpt as follows:

“The captain stated that almost immediately upon entering the top of the fog layer they received an ICE caution message. He stated they turned on the wing and engine inlet anti-ice, but the ice accumulation on the windshield wipers was rapid and ice was accumulating on the winglet.”

●     In another ‘same-year’ accident, from the report titled: Crash During Takeoff in Icing Conditions – Challenger 601, Montrose, Colorado (November 28, 2004), we have the following excerpt:

Effect of Wing Surface Contamination on Airplane Performance

“Previous Safety Board investigations of takeoff accidents involving airplanes with contaminated upper wing surfaces have found that the presence of a small amount of surface roughness on the upper wing surface can reduce maximum lift by as much as 33 percent, depending upon the extent and level of roughness. Wind tunnel and flight-testing by the accident airplane manufacturer indicated that the presence of surface roughness equivalent to 40-grit sandpaper on a CL-600-2A12-type wing can reduce the stall AOA up to 7º compared to the stall AOA of an uncontaminated wing. Once localized airflow separation begins on a portion of a contaminated wing, that wing can stall before the other one, which results in lift asymmetry and large roll rates that are not responsive to control inputs.”

Considering AOAc is generally in the neighborhood of 12 to 15 degrees for most aerofoils, the 7 degree influence of main wing icing referenced in the excerpt above is significant.

In closing, icing can be dangerous for variety of reasons, only some of which have been touched upon here. I hope our short discussion on these unique stall-related phenomena was of value and perhaps even prompted a few readers to investigate further. Know your pre-takeoff countermeasures, airborne mitigations and your airplane’s performance limits. ‘Preventing’ a loss of control in-flight event is always preferred to getting to the point of where ‘upset recovery’ is the only option. Prevention skills lie within the capabilities of the attentive, aware and appropriately knowledgeable pilot. Be prepared ✪

Sincerely,

Paul BJ Ransbury, President
Biography: http://tinyurl.com/ransbury
Aviation Performance Solutions (www.apstraining.com)
Proud Provider of In-Flight Upset Recovery Training for Bombardier Leading Edge

Through the work of Dr. Ted Fujita, Dr. John McCarthy, and others, those crashes have been eliminated. The last wind shear-related commercial airline crash was in July, 1994.

Since an entire generation of pilots has come into the field since those grim days, lets take a look at the state of downburst forecasting and how it relates to aviation.

One of the most important developments is known as WINDEX, a downburst prediction algorithm. It uses the atmospheric temperature and humidity sensing capability of the GOES Weather Satellites combined with the computer models to look for steep lapse rates combined with saturated air around 10,000 ft. AGL (known to meteorologists as an “Inverted V” sounding). The WINDEX data is available on the web at:  http://www.orbit.nesdis.noaa.gov/smcd/opdb/aviation/mb.html

In this example, from September 26, 2012, WINDEX forecasts (given that a thunderstorm occurs) values of 65 to 68 knots over northwest Texas as a line of thunderstorms begins to form west of the downburst threat area.

Three hours later, downburst winds were indeed observed:

This is pretty typical of the accuracy of the WINDEX product. It will not produce perfect velocity forecasts but it will certainly highlight areas of major downburst risk.

Because the GOES satellite’s sensors cannot take accurate measurements in areas of extensive cloud cover, no forecast will be made in those areas. With that qualification, you’ll find WINDEX to be a useful element to any flight briefing when convective weather is suspected.

The literature of aviation safety is peppered with references to the percentage of aircraft accidents that result from so called “human error,” that is unsafe acts committed by humans. Some studies show the percentage as 50%, some 75%, some as high as 80%.

Perhaps even the highest of these percentages is too low.

The figure should be very close to 100%.  If no unsafe act attributable to a human is apparent along the sequence of events leading to a mishap, then we may not have looked hard enough in the right places.  For example, in such cases we may have overlooked an error of omission committed by support personnel.

That is not to say that all aviation accidents are preventable.  Some very few probably are not.  A somewhat far-fetched example would be the improbable crash of a corporate jet due to a meteorite strike during high altitude flight.  In addition, some rare accidents inevitably must result when one takes calculated risks where the probability of an accident is very, very low.  For example, we routinely fly out of airports where birds congregate during seasonal migrations or in some case over prolonged periods of time.  Extensive measures can be and are routinely taken to discourage birds from congregating around airports, but in the final analysis, the risk of an accident caused by birds cannot be reduced to zero without simply grounding all aircraft.  In this example, a risk-benefit analysis dictates that routine flights continue despite the presence of birds around airports, and the consequence, of course, is the occasional very rare bird-strike accident.

Nevertheless, many accidents that seem unpreventable actually are preventable, and others that occur because of a calculated risk can be reduced in number or severity by implementing appropriate risk-mitigating actions.  Consider, for example, an aircraft accident that results from a deer-strike on departure from a rural airfield without a control tower in the pre-dawn hours.   At some point, someone in the deer-strike mishap sequence likely had the ability to prevent or reduce the probability of the collision.  Perhaps it was another pilot who nearly hit a deer a month ago and could have suggested a NOTAM, but didn’t.  What about the mechanic who noticed deer near the runway at the crack of dawn the day of the accident but didn’t feel an urge to ensure someone was addressing the issue?  Maybe it was the airfield manager who knew there is a hole in the wildlife perimeter fence but was waiting for better weather to go out and repair the damage.   Perhaps it was the mishap pilot who knew that deer sometimes encroach on the field around the time of the planned departure, but didn’t practice any risk management at all when considering the chance of a deer-strike.  Each one of those individuals recognized an operational hazard and elected not to take action.  Each individual had a unique opportunity to break the mishap chain, but didn’t.  Complacency comes in many forms, but it always reflects an unprofessional attitude that fosters the growth of error chains.

Each of the individuals in the hypothetical deer-strike mishap is accountable for the actions he or she did not pursue to address the perceived hazard.   Perhaps without being aware of it, each was empowered to act but failed to do so.   A strong sense of professionalism would have created motivation for action, but such was not the case.   Instead, potential actors remained mere spectator to a threat…passengers to the unfolding situation.  However, it is likely that none of the individuals in the accident chain, other than the mishap pilot, will be held accountable.  Many will not even perceive that they had an opportunity to decouple the mishap chain.  Their failure to act dramatically illustrates why empowerment to act for safety must be taught throughout an aviation organization and why positive actions influencing safety must be rewarded.   The responsibility to support safety by positive actions must be clearly understood by each member of the organization; it must be part and parcel of each member’s sense of what it means to be aviation professionals.

The deer-strike scenario is a vivid illustration of the damaging nature of complacency in aviation safety at the same time that it reveals the tremendous potential of safety-minded and empowered professionals.  Imagine an aviation industry where each employee pursues initiatives to enhance operational safety and holds him or herself accountable whenever inaction or omission strengthens a mishap chain of events.  Imagine a community of aviation professionals where every member feels empowered to function as a safety officer.  Such ideas may sound utopian, but they are not.   They speak of a spirit that must increasingly pervade our industry if we are to continue improving what is already a remarkably low accident rate.

Despite the obvious desirability of empowered accountability, some industry leaders have not been fully embraced the potential gains that such an attitude brings to safety.  Leaders must ensure that employees are trained in the causes of unsafe acts and their relationship to aviation accidents.  We must all learn how to recognize and properly report perceived unsafe acts and conditions.  We must also understand that we will be held accountable if we could have prevented a mishap but instead opted for complacency, thus allowing a mishap chain to propagate.

How much training, if any, does a typical FBO employee, airline ramp agent, dispatcher, or flight attendant receive on the subject of empowered accountability?  Many of us in a position to recognize and break a developing mishap chain remain ignorant of how accident chains are born and grow.  Mentally we are “passengers” in our own industry.  It will not be trivial to reverse this situation.  Many people regard a “philosophical” topic—such as such understanding how personal empowerment and accountability relate to accident causation—with muted disdain.  Some may find the topic too challenging to undertake.  Others still are comfortably numbed by the notion that their flight department has not suffered a major accident; as if such a fact somehow protects operators from future tragedies.  Perhaps these excuses help explain why too few employers include the concept of empowered accountability in their personnel training programs.  Yet without a philosophical foundation for our safety actions as aviation professionals, we are left to operate with a massive cerebral “blind spot” in an industry where blind spots cannot be afforded.

Empowered accountability is an excellent way to remove such blind spots.  The concept teaches us to engage our mental radars and constantly scan for hazards; then to take action.  Which begs the question: what have we each done recently to empower those who can detect and break developing accident chains?

Authors:

and

Stress compels your body to action. If you’re stressed, your body desperately wants to run away from the “rat boy monster-thing” or fight to the death. But, it’s bedtime. You’ve already fought with a) your boss, b) your spouse, c) your children, d) the dispatcher, or e) all of the above. Running away doesn’t make any sense because you’re in a pretty decent hotel room and you’ve got to get up and go to work in the morning, so you toss and turn while the carnival plays in your head. Here are a few ideas to silence the music:

 1.    Get out of bed. Grab the handy pen and pad that the hotel has provided for just these moments. Write a list of everything that’s stressing you out. Sometimes it’s a list of things you need to do. Either way, write them down and spend five minutes prioritizing when, what and how you’re going to deal with them. Decide that they are challenges to be conquered, not problems that are going to hurt you.

2.    Stretch out the kinks. Do a little easy yoga or stretching to loosen up the tension you’re carrying around between your shoulder blades. Don’t work up a sweat, just a couple of minutes of gentle stretching.

3.    Think happy thoughts. Close your eyes and visualize the image of a flickering candle flame, a campfire, a flowing stream, or waves at the beach. Breathe deeply and slowly. It’s okay to yawn.

4.    Try Standdown’s Ocular Gimbaling Technique: relax your shoulders and take a deep breath. Let it out and gently roll your eyes up as far back as you can. Take another deep breath. Let it out and let your eyes return to normal. This helps your brain transition from the high-stress beta wave pattern to the relaxed alpha-wave mode.

5.    Get back in bed. Now it’s time for progressive muscle relaxation. Tense and relax one group of muscles at a time. Start with your toes and work your way up.

Even better is burning up all of that stress before you get to bed time. Aerobic exercise boosts the production of neurotransmitters that help calm and slow down the body’s processes that have been amped up by stress. Thirty minutes of strenuous exercise every other day will help keep the stress in check and allow you to sleep better.

Finally, regardless of Stanhope’s assertions to the contrary, it is better to go to sleep sober. The sleep you get will be higher quality and you’ll awake more refreshed, ready to take on those challenges that you listed the night before. If you find the carnival starting up again, go back to the visualization step and you’ll find yourself drifting off. Pleasant dreams!

See more on Pat Daily on our Experts page here.

One thing I look for each year are the inspirational quotes that you have in the conference area. I believe that words have power – who can not be moved by our greatest speakers like JFK, MLK, Churchill and Lincoln to name but a few and I use quotes in my monthly departmental safety newsletter as a way to inspire my group.

Having said that I would like to contribute a quote for your consideration. First a little background. My nephew was a decorated veteran and Deputy Sheriff in our county. He was instrumental in starting their K-9 corps, and as a result he led their community out reach program. Kyle was in great demand in our local schools and he loved bringing his partner Jynx into a classroom and speaking with the students. In addition to letting Jynx show off his skills his message was always positive. At the end of his presentation he would invariably leave the kids with these parting words:

“If you stopped yourself every time you said, “I have to”, and changed it to, “I get to”, it might change your entire experience.”

Tragically Kyle was murdered last year while serving a warrant.

The first time I heard him tell a group this it struck a chord deep inside of me. Kyle wasn’t a pilot, but who knows this feeling better than one of us? Many are the times that I sat in my cockpit and wondered at the fact that “I get to” do what I do. And no matter how long my day had been or adverse the flying conditions, the fact that “I get to” do something that I love made everything worthwhile.

Since this quote resonated with me so much I thought it might be something you would also appreciate.

Thank you all once again for your hard work and continued dedication. I look forward to seeing you again next year.

Nicholas A. Pagerly

The next few years will be pivotal in aviation safety. We have a serious pilot shortage looming on the horizon due to the age 65 rule requiring airline pilots to retire and the military not turning out the number of pilots as it did in the past. Even though economies are bad thousands of new commercial and business aircraft will be introduced into the system. We’ll need tens of thousands of new pilots whose training will determine whether or not aviation remains the safest form of transportation or accident rates increase dramatically.

As professionals, we must take responsibility and realize that there must be more than training to the minimum standards required by the regulations. Bombardier Safety Standdown is a giant step in that direction. Safety Standdown offers those who have the courage to discover what they don’t know that they should know, the opportunity to gain that knowledge. Once Learned, Standdowners can Apply the knowledge and Share it with others.

SEE YOU AT STANDDOWN!

Cheers,

Rick Rowe
Manager, Safety Standdown Programs

Dear Safety Standdown team,

I am writing with regards to the Safety Standown Latin America held yesterday and today in Sao Paulo, Brazil.  

I attended today’s seminar and was very impressed with the event, from the infrastructure to the lectures. As I wrote on my feedback form today I see the Safety Standdown as a great initiative of Bombardier towards improving the safety of aviation as a whole. Like Dr. Tony  Kern said on his lecture today, safety issues affecting one part of the aviation community in today’s globalized world end up affecting the whole field. In my opinion, the same applies to the learn-apply-share philosophy presented today throughout the seminar: all of the concepts learned today when applied and shared by the atendees will turn into benefits for the whole community. Therefore, I was glad to have been given the oportunity to attend despite working at one of Bombardier’s competitors in the aviation industry, Embraer. Although the seminar was directed mostly towards people closer to the operational activities, I find that I will indeed have opportunities to apply and share what I learned today in my work as an engineering supervisor.

As if the benefits from the learning weren’t enough, I had the priviledge of having my name drawn and won the Ipad in the end of the seminar. In addition, I had the honor of meeting Capt. Eugene Cernan and Mr. Marcos Pontes also.

Unfortunately I was not able to stay for the cocktail reception after the seminar since I had to return to the city where I live right as the reception began. But please accept through this email my thanks for opening the seminar to my participation and my congratulations for setting up a great event. As I know Capt. Gene Cernan is also part of the Safety Standdown team, I take the oportunity to reinforce what a priviledge it was to meet him, such a high achievement fellow Purdue graduate. I would greatly appreciate if you could foward to him my message of admiration and regard.

Thank you again for the opportunity and I hope to be able to attend again in the future.

Best regards,

Luiz Felipe R. Valentini

Likely, everybody made the same of me [felt the same way] and reconsidered their acts, trying to be best everyday and perhaps a ‘Professional Level 3′ [in reference to Dr. Tony Kern's presentation].

Thank you for this experience.

Leonardo Calix

Listening that Capt. Eugene Cernan, Paul Ransbury, Glenn Harmon,  Dr. Tony Kern, Capt. Rick Rowe and Dan Boedigheimer I realized that how a pilot I need do best of the best and not accept, tasks poorly done in special in aviation. Paul told of an importance of training upset recovery and this information can save my life one day.

Thanks Very Much.

Sergio de Souza
Aircraft Technician Tam Airlines
General Aviation Pilot