Air Line Pilot, January 2003, p.34
By Capt. Tom Duke (Ret.)

This was an opportunity for students to mingle with other candidates in related specialties from all over the world, including government and airline industry candidates from Ghana, Holland, Sri Lanka, Switzerland, Syria, the Royal Air Force, Transport Canada, and the International Air Transport Association. The United States was represented by two Department of Interior pilots, the directors of safety of smaller and low-cost U.S. air carriers, a large airline fleet chief pilot, a Boeing analyst, flight line supervisors from Newark International Airport, an owner of a fixed-base operation, two FAA headquarters specialists, and people from MITRE Corporation, among others. The faculty was made up of expert movers and shakers in their subject area.

GWU’s program began in 1997 as a result of the Gore Commission’s call to improve the U.S. aviation safety record. Candidates for the GWU certificate are required to take a 2-day core course in aviation safety and security management and one in safety data management and analysis. The students must also complete a case study monitored by the GWU program director, Vahid Motevalli. Nine 2-day elective courses are offered throughout the year. Candidates must complete three of the electives to complete the certificate. The graduate school recognizes the needs of the working candidate and can tailor almost any elective program to serve students.

Having a lifelong interest in airline safety, I managed to sit in on the 2-week program to take the pulse of the future and sense where the experts are taking us. I also sought to see how career pilots could contribute to improving the safety management of the airline industry. I was very pleased with what I witnessed and wish to encourage more line pilots to enjoy the possibilities and rewards. Even the roundtable breakfast and lunch breaks were illuminating. The school provided hope that an already "better" airline safety record can continue to improve with the proper mix of brains and energy.

The course began with Dr. Dave Huntzinger, a former Boeing accident investigator and vice-president of safety at America West who holds a rare Ph.D. in safety, at the PowerPoint remote control. A consultant now, he is president of VP Safety, Inc., running the flight safety program for a worldwide jet charter operation. Among the first slides he showed was the Boeing chart that attributes pilot error as causal in 71.7 percent of worldwide large jet hull losses. The chart implies that most of the safety problems of U.S. carriers can be solved by making pilots smarter or formerly employed. Dr. Huntzinger pointed out that the data show that airline pilots need to get enough accurate information and organizational support to eliminate errors before the unintended event. Simply blaming the pilot impedes all other efforts to prevent other causes and allows problems to remain.

Other safety concepts Dr. Huntzinger covered were the frequency/severity triangle and James Reason’s Swiss cheese model.

The triangle model concludes that for every fatal accident, 10 serious accidents involving severe injury or substantial damage occur, plus 30 minor incidents or accidents requiring trip cancellation and 600 events often expensively disrupting safe operations. The theory is that, to reduce the numbers at the top, we intercept and reduce the high-frequency, lower-severity events that could lead to accidents by reporting and fixing those problems.

Reason’s analogy—in which slices of Swiss cheese are stacked—illustrates the need to design deep barriers (more cheese and fewer holes) at each level of the aviation system. Accidents happen when all the system’s imperfections (holes in the cheese stack) line up. The system levels (the cheese in the slices) include crew selection, hardware, ATC, and procedures.

Dr. Huntzinger pointed out that a hull loss may cost $100 million in direct costs, but the total loss will be almost four times that in indirect costs from lost revenue and work time, disruption of flight schedules, and negative customer reaction. A good accident-prevention process and safety department can never cost more than an accident.

Good safety management involves gathering data, analyzing risks and cost/benefit ratios, and buying into a concept of perpetual improvement with all employees involved and informed in the process.

Capt. Ed Soliday, former vice-president for safety, quality assurance, and security at United Airlines (and an ALPA member), illustrated how his 400-person staff worked full time on the problem. Capt. Soliday actually had fewer than 100 people directly working on safety as such, but combined the efforts of his managers and directors of quality assurance, corporate security, occupational safety, environmental safety, information security, and administration into a massive oversight and continuous improvement project. His airline safety report system draws 11,000 responses a year from employees, mostly flight crews, and 93 percent of those reports get responses.

Noting an unsatisfactory trend in flight attendant injuries, his people investigated and found that the then-current procedure to get the cabin occupants all strapped in upon notice of turbulence ahead took almost 8 minutes. The procedure they came up with may not be the final answer to the problem, but it requires that the service carts be secured in the aisles and the flight attendants seated within a minute. For 2001, the NTSB database listed no serious United flight attendant injuries from turbulence.

United is deeply involved with Flight Operations Quality Assurance (FOQA) and believes that the information belongs to United and not to the FAA. Capt. Soliday made sure his first duty was to report to the organizations that could fix the problem (including ALPA).

As gatekeeper, he provided no-jeopardy, deidentified, and grouped FOQA analysis to his boss, to the division head, to senior management, to review boards, and to the United Board of Directors. Safety became a part of the corporate culture.

Capt. Soliday also communicated regularly with other airlines, national committees, and organizations.

His emergency response plan for United was exercised regularly to ensure all went well when either his airline or its code-sharing partners had a tragedy. His view is that "safety, quality assurance, and reliability are the same and use the same techniques." He also believes that accident investigations identify the problems, but airlines fix them. Ideally, airlines should find and fix the problems first, before an accident occurs. ALPA agrees. (See "A Visit with Ideal Airline’s Flight Safety Department," April 2000.)

The safety data management and analysis segment of the program was taught by Dr. Sherry L. Chappell of Delta Technology, whose task was to teach how to "make sense of safety data without getting buried in it or fooled by it." She is a former analyst with NASA’s Aviation Safety Reporting System, the now-familiar program that offers anonymity in exchange for reporting the unintentional scary stuff. NASA receives around 3,000 of these confidential reports a month, about 70 percent from airline operations. The intent was to have all this self-reported information translated into useful aviation safety improvements.

Dr. Chappell is now working on human factors analysis for Delta for its Aviation Safety Action Partnership (ASAP) pilot reporting system, seeking answers for "why it happened" and assembling "how to prevent it from the participant’s point of view."

She also discussed FOQA, which can be used to suggest improvements in aircraft systems, pilot procedures, and air traffic procedures based on quick-access recorder (QAR) information from aircraft flight data recorders.

Quite often, FOQA and ASAP, when used together, can identify trends, correlations, and precursors to events and help formulate remedial actions. One great challenge is to sell what the data are saying to the people who can make the improvements for safety.

Another complication for the safety professional was the topic for John R. Harrald, director of GWU’s Institute for Crisis and Disaster Management. Most CEOs understand the concept of risk management and equate safety efforts as "reducing risk," he said, but "most company employees perceive accidents in different ways—for example, engineers see accidents as systems or component failures, psychologists as the result of human factors mistakes, regulators as compliance failures, managers as performance failures, and sociologists as a societal failure.

Assessing risk with credibility is a tough sell within airlines as the chance of dying in an airplane is less than that of dying in a high school football game. Risk levels are highly dynamic with multiple variables. Formulating models that offer a picture of the degree of risk involves making assumptions. The real purpose of designing the models is to propose and evaluate interventions for reducing the risk of accidents. The key is to develop an accurate, balanced, and informative synthesis and do no harm.

Recently retired American Airlines Vice-Chairman Robert Baker taught the first day of the airline operations course. Having come up through the ranks at American, he is intimately familiar with all phases of airline management in good times and bad. He explained that airlines are extremely capital intensive and continually try to hold down costs. Airlines must grow to become profitable.

Baker described how his command center handled operations when they fell behind schedule, such as after an accident or during extreme aircraft rerouting, both of which happened on Sept. 11, 2001.

Baker also explained American’s prototype Aviation Safety Action Plan (ASAP) reporting program and Advanced Aircraft Maneuvering Program (AAMP). He stated that ASAP reports improve the safety information flow by 99 percent with only 1 percent of the reports needing the protection of NASA’s ASRS reporting system. The FAA, as part of American’s team along with management and the in-house pilots union, is privy to much more nonregulatory safety information before accidents or violations occur, thus enhancing prevention. AAMP, with many more safety matters to cover than sim time available, is a work in progress.

Baker explained that airlines are still heavily regulated and depend on the U.S. government to lead with change on all but routing and fares. Safety change comes from the bureaucratic and consensus-laden rulemaking process and usually costs airlines critical dollars. Baker admitted that airline managements rarely take initiatives on their own for safety—they tend to wait for all-industry mandates. As for meeting the goal of reducing airline accidents by 80 percent by 2007, Baker would have preferred four or five specific targeted improvements. The government/industry Commercial Aviation Safety Team (CAST ) committees, formed to help airlines reach these goals, are just now issuing their reports, almost 5 years in the making. Aviation security measures instituted since 9/11, plus the dropoff in airline-passenger traffic, now leave both government and the airline industry with precious little extra money available for safety. Tradeoffs abound.

Darryll Jenkins of the GWU Aviation Institute challenged the class with economic concepts that seemed illogical for airlines to make a profit. He says that profits depend on filling one more seat and that the marketers now running most airlines are chasing that formula. The business traveler paying top price seems to be the key, and airline marketers have computers constantly maximizing the dollar-per-seat game. In essence, route networks can succeed only when an airline expands its route structure to the largest size it can get away with without going too much in debt! Airlines do not compete on price because all of them have competitive weak spots. The ideal hub is both a feeder and an international gateway serving a large number of business travelers. Currently, 9 percent of the seats provides 40 percent of the revenue. Jenkins asked the students to brainstorm ideas for helping airlines back to stability and profitability.

Jerry Green, a consultant, and Martin Thon, a retired manager for Northwest Airlines, taught the section on dangerous goods, or hazardous cargo. This was the class’s chance to apply the IATA Handbook and regulations on shipping hazmat safely worldwide. The experts guided the class through work projects with specialized cargoes including explosives, radioactive materials, and infectious substances. The lessons of ValuJet and the speed at which the air cargo business is growing were a strong motivating factor for the class. In 2 days, the students became familiar with international standards for packing, labeling, and handling one of aviation’s most critical elements.

No course in aviation safety is complete without learning about the NTSB’s investigation, reporting, and recommendation process. Dr. Barry Strauch, deputy director of the NTSB International Academy, led a team of NTSB investigators-in-charge (IICs) plus a general counsel in teaching a 2-day cram course. They discussed the legalities of investigations, human errors in accidents, conducting various categories of investigations of both domestic and overseas accidents, and some tricks of the trade. ALPA accident investigation training courses cover most of the topics, but one of the students who had taken them explained that getting a deeper and broader look at anything is always a benefit.

Dr. Strauch explained the role of accident antecedents, such as equipment, operator, team, company, maintenance, regulator, etc., in making decisions or taking actions that can lead to damage or injury. Often accidents occur because of a loss of situational awareness or because timely, sufficient information was not available for a proper rapid decision-making process. Humans make mistakes, and through technology, training, or procedures, we can design ways to intercept the antecedents to reduce the possibility of making them again. Human factors analysis has changed the way we look at pilot error.

Kathy Silbaugh presented the legal counsel’s angle on the conduct of the NTSB’s 2,200 or so general aviation and airline accident investigations per year. ALPA investigators, as recognized experts on the subject matter, are able to provide "suitable qualified technical assistance" as a party to investigations when members are involved. Every investigation has a boss and a group chairman, and only the IIC or Board member on scene may talk to the press. Silbaugh also walked the class through how different nations treat accident boards, including confidential testimony of witnesses and crew members in civil and criminal trials.

Jeff Gazetti, formerly of Cessna and now an IIC at the NTSB, told how the ideal investigator conducts an aircraft accident investigation—take a "go bag," a good credit card, a curious mind, a calm demeanor, and a collaborative spirit, and know your boundaries and duties. Take good field notes. The NTSB staff writes the report itself, but participants are involved in the process.

Bob MacIntosh, formerly of Saudia and a long-time IIC at the NTSB, examined the procedures and meetings involved in major and international investigations with U.S. involvement. Investigators should always keep accident prevention, not blame, in mind while involved in investigations. IICs are accredited representatives at almost all worldwide airline accident investigations because U.S. interests are usually involved. Often the government of the country in which the accident occurred asks for NTSB help. It is an international effort.

Not to be confused with safety, which involves unintentional events, aviation security deals with the prevention of intentional events, such as crime and terrorism. "A good aviation security system," according to Leo Boivin, formerly an FAA international airport security assessment manager, "must be good, fast, and cheap—two out of three does not work." Security guidance is found in ICAO Annex 17, which is usually adopted by the 190 signatory states. The United States had been admittedly lax in its security commitment before 9/11. Now it is draining all its priority funds to catch up and provide the best, fastest, and most cost-effective aviation security system.

Boivin briefed the class on all the new technologies and thinking, including 100 percent baggage screening, biometrics, and improved explosives detection. Before 9/11, the FAA had 1,100 employees involved in security. By Sept. 20, 2002, the new Transportation Security Administration was supposed to have 62,000 employees and to have spent $4 billion in system changes. So far, checked baggage has not been included in either personnel or technical needs. The TSA is in the police-thinking mode and has coordinated little with aviation management or airlines.

Airline accident rates appear to be trending down. Dr. Strauch noted that only three fatal major passenger airline accidents have occurred in the United States in the last 5 years (Little Rock, off the California coast, and New York City). These do not include all the airline accidents involving nonfatal hull losses nor cargo, ramp, regional, or Canadian operations. Seven other major Part 121 accidents have involved multiple fatalities and/or a destroyed aircraft, and seven more severe single-fatality accidents occurred since 1997. These 17 accidents and about 50 total airline accidents per year at around $500,000 apiece in direct and indirect costs provide ample motivation for increased professional efforts for accident prevention. The costs loom large as airlines also concentrate on bottom-line health, and the airline industry’s safety improvements are just now at the inception stage.

Capt. Soliday pointed out that more than 150 airlines operating in the United States need safety organizations. One student, Atlantic Coast Airlines Director of Safety Joe Hexter, has just initiated an ASAP program that is already handling more than 120 reports a month, a majority on ATC-related problems. These safety initiatives are beginning to uncover more systems failures in places that are outside the cockpit but that lead to accidents. Who knows the system best and should be heard? John O’Brien, director of ALPA’s Engineering and Air Safety Department and member of the GWU program’s Advisory Board, exclaims, "Who better to get involved in the investigation, analysis, and proactive interventions than the cockpit crews?" Courses such as GWU’s are a great way to learn some of the ideas and tricks of the trade for your airline’s safety and financial health. A great deal is yet to be done.

For starters, the website is www.gwvirginia.gwu.edu/academics/aviation or e-mail vahid@seas.gwu.edu.