I recently wrote a Frequently Asked Question (FAQ) for this web-site about airframe icing, and included a short anecdote about my experiences with ice and frost on the wings of an aircraft. The story is recounted in summary below;
I remember flying a Beechcraft Baron as a charter pilot about 25 or 30 years ago, and had to overnight in Armidale in winter. Next morning, although the day was clear, the frost was like snow. The aircraft wings and other surfaces were coated in a heavy layer of frost. I found the only container which would hold water (a garbage bin) and proceeded wash down the wings and tailplane to remove the frost. It was so cold that the washing water froze on the wings almost as fast as the frost was removed. The customer was not happy because he wanted to get going, and it was only frost – what’s the problem?
Since writing the piece, I have started to think about any young charter pilot’s capability to handle ignorant (in both senses of the word) and demanding passengers. In my experience the pressure which can be exerted can be overt and obvious and other times it can be covert and subtle. I’ve had it from every quarter and realise in retrospect, that the pressure can be significant enough to influence safety. I have been thinking about how this risk can be treated.
A good general aviation Chief Pilot may provide induction training on things like, the provisions of the operations manual, aircraft familiarity, route and charter destination aerodromes, maybe some un-documented work practices, and even “keep your eyes of the receptionist sonny!” A real professional might talk about CRM and some human factors issues, but I wonder if the practical aspect of human “pressure” in all its forms is ever discussed.
More significantly, I wonder if the issue is ever raised by pilots who have recognised and resisted the pressure, and, having done so decided that it was an important lesson for others to learn. The culture of the organization needs to encourage and support lessons from within as well as other training.
Whilst acknowledging that it is easy to be an armchair expert and dream up all types of scenarios which relate to safety, I think it is important that any aviation organization of what ever discipline, creates and maintains a culture of continual learning about things which pertain to safety. It is also important that the lessons are contextual and relevant to the activity. In my early days, the training was done around the bar after a hard day’s flying and all types of issues were discussed; I cannot remember a lesson about pushy customers though!
This sort of ‘training’ does not need to be rocket science, but needs careful thought by the organization’s leaders to ensure that the culture includes a learning element, and that training in what ever form, hits the safety target. A safety culture is a learning culture.
I read a recent article in the Flight International magazine about a Boeing 737-800 aircraft operated by a well known low cost carrier which was involved in an unplanned and highly unstable approach at Rome’s Fiumicino airport.
Apparently, the crew had previously attempted to land at Ciampino but due to significant thunderstorm activity, had to divert to another airport. Instead of diverting to the planned alternate, Pescara, the crew decided to divert to Fiumicino instead. The aircraft conducted an approach which was very unstable and unsafe. It crossed and recrossed the extended centreline of the left and right runway a number of times, and at one stage was 770 feet below the correct profile altitude of 2200 feet. Eventually, after promting by the First Officer, the Captain abandoned the approach and diverted to Pescara which was the original planned alternate.
Thankfully, the flight ended safely but the ensuing investigation revealed a number of interesting organizational and human factor issues which may have contributed to the incident. They include;
• The Captain’s 3 month old son had died a few days before the incident. He did not inform anyone of his situation because of concern for his job.
• The First Officer’s experience was just 475 hours total flight time of which 300 hours was on type.
• The First Officer had not previously flown in adverse weather conditions.
• The crew did not brief each other properly and did not update the Flight Management System (FMS)
• The aircraft was being flown manually during a high pressure situation.
I am not casting judgement on the crew in this situation because, “But for the grace of God go I or we!”
As a result of the incident, the operator has amended its operations manual, among other things, to emphasise the safety implications of personal trauma. In my experience, this issue is rarely covered adequately in company operations manuals and induction training.
Of greater concern is the Captain’s perceived worry about the security of his employment, hence his reluctance to inform the company about his personal situation. This was presumably because he would require some time off. This may have been a justifiable concern or one which has been invented in the Captain’s mind. (We all do this occasionally.) In any event, I think that this issue may indicate something about the culture of the operation.
Further to this, I asked myself; do some aviation businesses have little “heart” and “eat” people as though they are a consumable commodity? In my experience, the answer is YES. Can this have an impact of safety? Again, the answer is YES. Is this identifiable and can it be addressed? The answer is YES!
The operational lessons learnt form this particular incident are obvious, however the organization and cultural issues are subtle but no less important. It is the role of Boards, Management, Consultants, and the Regulators to identify when the heart of an organization is showing signs of disease, and take remedial actions. Sometimes a check up by an independent and knowledgeable person can prevent a heart attack!
