General aviation Quality Safety

Documented procedures and the operation

Written by Sergio Romero

My Ray Ban glasses I use after my old man’s costume are part of my standard procedure in this summer beginning. I was called to go the Flight Operations Office to talk about common endeavors in this airline I just got into one week ago. It’s December bunch of calendars ago.
We are just obssessed with words like Standardization, Training, Check Rides, Safety Culture Effectiveness, Assessment, among others.

I took my steps slowly and sober to be right on time for the LOSA session we designed and it is beginning to work fine. One may read a lot of books or publications about one stuff, but going upstairs to the airplane ready for embarking makes me thinking on safety, but for real. Humans behave as to the culture they are living within and cannot help it. Humans are in a rush, sad, or even way too excited or fatigued, and there are a lot of procedures to be followed.

Training makes the difference in this kind of technological-social contexts. These human beings, these front line workers need to be trained to react properly before sudden events appear. I remember one Captain saying the good difference lied on how a trained pilot reacted to a fire on ground. The plane was a full BER, but lives were saved for sure. I guess this matches the following concept I read once in Skybrary: “An operator shall establish and maintain a ground and flight training programme, approved by the State of the Operator, which ensures that all flight crew members are adequately trained to perform their assigned duties. The training programme shall include proper flight crew coordination and training in all types of emergency or abnormal situations or procedures caused by powerplant, airframe or systems malfunctions, fire or other abnormalities. The training for each flight crew member, particularly that relating to abnormal or emergency procedures, shall ensure that all flight crew members know the functions for which they are responsible and the relation of these functions to the functions of other crew members. The training programme shall be given on a recurrent basis, as determined by the State of the Operator. (ICAO Annex 6 Part I: Operation of Aircraft, Chapter 9 Para 9.3.1)”.
What could we tell about it? Which are the keywords here? Coordination, Training, and Crew Member functions knowledge. Then, I completely agree with Frank Ayers saying “it appears that everybody did their job just as they’re trained to do”, when speaking about Captain Sullenberger performance in the Hudson River some years ago.

The Flight Operations V.P.’s office looks quite nice to me. I took a cup of black tea, and began just talking after the captain makes orderly movements with his tie. We discussed these items:

– Standard Operating Procedure for short runway landings.
– Risk Management for unpaved runways. Did you do it, I asked. Well, that’s the SMS guy’s job. Let me check it out, he replied making a strange face.
– Monitoring for Engine Starts in hot weather airfields.
– Safety Promotion Activities design, execution and monitoring.

Are we making history here? Are we creating a Safety Culture? Coordination and Information shall make the difference in Safety Management, believe me guys. We write a lot of documents. We live with words or concepts like documented and implemented, documented but not implemented, that we are loosing the real perspective. Do not live trying to tick those boxes. We got to assure our operational staff is informed about what to do in the flight deck. Procedures neat made along with the relevant records are fine for the auditors, but assurance has to be achieved, based on the confidence the organization has gained in these circumstances. It will do good when everyone knows about the operating procedure, has been trained how to follow it, drills have been performed and monitoring has been made for proper actions and even improvement.

As I continue the talking with the captain, I also remember one of my favorite movies: A Few Good Men. Astonishing performance by Tom Cruise and Jack Nicholson. Do you think everything must be documented? That has been my question for an issue to be raised in a Human Factors Course I must deliver one of that days. What does FAA’s AC 120-71 state? “Standard operating procedures (SOPs) are universally recognized as basic to safe aviation operations. Effective crew coordination and crew performance, two central concepts of crew resource management (CRM), depend upon the crew’s having a shared mental model of each task. That mental model, in turn, is founded on SOPs.” It is clear we are talking about the operation as the ultimate and sacred value. Crew Members in flight decks need these SOPs to share mentally what to do in any circumstance, which makes me recalling my days as a soccer player at the German-Peruvian school team I was part of as midfielder. We have a goal, we have a plan, but as several and different situations arise, we decide what to do and how to do it, based on training and skills. So, documentation on standard operating procedures shall be made with a risk-based approach, basically, taking into account skills and training of the pilots. Let me share now some quote excerpts of the movie I was just speaking before:

Capt. Ross : Corporal Barnes, I’m a Marine. Is there no book, no manual or pamphlet, no set of orders or regulations that lets me know that, as a Marine, one of my duties is to perform code reds?
Cpl. Barnes : No, sir. No book, sir.
Capt. Ross : No further questions.
Kaffee : Corporal, would you turn to the page in this book that says where the mess hall is, please?
Cpl. Barnes : Well, Lt. Kaffee, that’s not in the book, sir.
Kaffee : You mean to say in all your time at Gitmo, you’ve never had a meal?
Cpl. Barnes : No, sir. Three squares a day, sir.
Kaffee : I don’t understand. How did you know where the mess hall was if it’s not in this book?
Cpl. Barnes : Well, I guess I just followed the crowd at chow time, sir.
Kaffee : No more questions.

Over the years of this 1992 movie, I now fully understand the mess hall is not part of the operation, and that is why poor Corporal Barnes could not find the chapter of Code Reds in any book, pamphlet or set of regulations whatsoever!

About the author

Sergio Romero