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Cockpit Discipline – Discipline as an Antidote

Posted on: September 29th, 2012 by Pete Agur

Cockpit Discipline

Discipline as an Antidote

The Importance of Procedures and the Adherence to Procedures Cannot be Understated

 

By Peter v. Agur, Jr., Managing Director & Founder

The VanAllen Group, Inc.

 

 

Event One: While sitting in the forward passenger seat of a light jet a few years ago I received a thorough safety briefing from the copilot as his chief pilot started the engines … without a checklist.  That got my attention since both pilots knew I was part of a team of auditors conducting a safety review of the flight department.  The chief pilot advanced the power levers to taxi just as his copilot stepped over the center console.  Strike two.  Finally, the chief pilot began the takeoff roll as his right-seater tried to discreetly hand his captain his seat belt. Strike three.

 

Event Two:  A senior executive with direct responsibility for a major company’s aviation department recently called me. He explained that one of his staff had flown in the jump seat on a short relocation leg.  The only other people on board were the crew, including Becky, the flight attendant.  Due to the aircraft’s light weight, its takeoff and climb performance were especially impressive. Hand-flying the airplane during a steep initial climb-out, the captain looked back at his jump seat passenger and said, “Watch.  It really [ticks] off Becky when I do this.”  The ensuing maneuver could easily be described as aerobatic.

 

Event Three:  Years ago, I was called in at the last minute to fly as copilot for a pop-up charter trip in the company’s E-55 Beech Baron. My captain was also our company president and my boss. The customers were three cattle buyers.  With two pilots up front, one full-sized passenger was crammed into the kiddie seat in the baggage compartment.  My boss taxied out and started the takeoff.  Although he had been an F-4 pilot flying inVietnam, I don’t think he had ever handled an aircraft with a center of gravity so far to the near. Neither had I.  The aircraft rapidly began to oscillate in pitch attitude, the excursions getting more violent with each gyration.  I called for the controls as we hit the zero-g apex of the next cycle. The aircraft settled down; the stomach of the passenger on the kiddie seat didn’t.

 

These three events are what a friend calls “stupid pilot tricks,” but to be more specific I’ll use the term PINC, coined by David Huntzinger, the newly installed chief of safety at Korean Air, for Procedural Intentional Non-Compliance. One of the most frequent contributors to aircraft accidents and incidents is PINCs.

 

PINCs are not always committed in the loose manner of the cited examples.  They are often the result of well-meaning pilots trying to do their job but willfully taking risks to achieve what should be the secondary goal, “completing the mission.”  These pilots lose sight of their first responsibility: managing risks to ensure safe outcomes.  However, when your efforts to get there include fudging the rules, you do raise risks.

 

PINCs raise risks, and there are a lot of PINCs happening out there every day.  But if you are in a position to do so, you can take a straightforward series of steps that are critical to prevent PINCs in your organization: (1) gain commitment, (2) budget and develop the resources and (3) ensure performance management.

 

Gain Commitment

Everyone says they want safety.  But if there were never a gap between mouth and movement there would be no PINCs.  We all learn early in life about the two sets of rules to live by: the formal rules — written or stated — and the “real” rules — those the game is actually played by.  When there is a significant difference between the two, the “real” rules become the standard.  The solution is to establish and maintain a universal commitment to the formal rules — that is, flight operations manuals, policies, procedures, etc.  That emphasis must start at the very top of the organization.

 

If the chief executive officer (CEO) of your organization is truly committed to safety, your safety program is set up to succeed.  A safety-committed CEO knows a PINC is grounds for severe repercussions, whether it is perpetrated by a technician, a scheduler, a flight crew or a senior passenger.  A safety-committed CEO is your chief enforcement officer.  Anything less leaves the door open for informal rules and resultant PINCs.

 

I’ve only met one executive who deliberately pushed his crews to be unsafe.  He raced offshore powerboats and climbed mountains for fun, and he allowed his sense of risk management to be totally skewed by his personal comfort with and affection for adrenalin.  The only way to get through to him was by getting personal, pointing out that his children were being put at risk, too.  His initial response was anger, but in the end his informal rules were realigned with more traditional policies and procedures.

 

The commitment from top management allows you to expect appropriate behaviors from passengers and service providers alike.  No PINCs are permitted, period.  With that understanding as a starting point, it becomes the aviation manager’s responsibility to get the necessary resources into play.

 

Budget and Develop Resources

Aviation professionals tend to be highly service-oriented.  They naturally push themselves and their equipment to get the job done, so it is critically important that their leaders and managers give them the right resources.  If the service delivery team doesn’t have the right resources, they will stretch the ones they have to make the customer happy.  The results of these heroic efforts populate accident investigation files.  Even a well meaning crew can be sorely tempted to commit a PINC rather than disappoint their passengers.

 

The most important resources are enough people, time and equipment to do the job. Also required are the guidelines for using them — effective policies, standards and procedures.  Those policies, standards and procedures are critical in ensuring the quality and continuity of organizational and individual performance, and the avoidance of PINCs.

 

Some aviation managers say vague policies and procedures create the flexibility they need to get the job done.  Wrong!  That approach sends a loud and clear message: safety is a variable, service is an absolute.  That sets the stage for people to push.  Lives are lost and hillsides are littered with aircraft wreckage as a result of crews pushing.   Weak policies and procedures send the wrong message.

 

On the other hand, standard operating procedures (SOPs) also must establish clear guidelines for the use of judgment in a way that continues to assure safety while being flexible enough to adjust to unique service needs.   Some aviation managers make a case for absolute SOPs that leave no wiggle room for judgment.  They are the enforcers, unwilling to take responsibility for using common sense. Overly rigid guidelines prevent the use of common sense to get the job done safely.

 

If you expect your folks to make informed and collaborative decisions that are biased to the safe side, it is critical to have a comprehensive set of operational policies, standards and procedures.  Once those are in place, it is up to the team to perform … top to bottom.

 

Performance Management

Commitment and resources are the foundation of a safe operation, but it is how they are applied, how the task is performed, that determines whether the job is done safely or not.  Actual movement must unerringly match the description.

 

Since safety starts at the top, your operational managers must not only be the champions of proper performance, they must be the models.  “Do as I say, not as I do” is not an option.

 

Even as these mid-level leaders set the example, operational managers must also constantly catch people doing things right.  They must routinely praise folks for taking the time and care to follow and implement proper procedures.  That praise is best given publicly.  In doing this, they are creating a culture of co-responsibility.  Co-responsibility is basic to effective crew resource management.  Each member is co-responsible for the rest of the team’s performance.  Everyone is a partner in performance.  This applies in ground and scheduling operations, too.

 

From a managerial perspective, each PINC event deserves unique attention and action. There are a few things to consider:

  • A PINC is a deliberate violation of an established policy, standard or practice.
  • A PINC often raises risks.
  • A PINC perpetrator is likely to commit future PINCs.
  • If other members of the organization are aware of a PINC event and they see no negative consequences, they may correctly assume management does not take the SOPs seriously.  That is a nasty can of worms you do not want to open.

Therefore, contrary to the old axiom of “praise publicly and punish privately.” I suggest the consequences of PINCs should be emphasized; the floggings should be public.  Not only does this approach provide positive public reinforcement of proper behaviors, it also applies strong pressure to avoid improper behaviors to prevent such public embarrassment.  The best way not to get caught doing a PINC?  Don’t do the deed.

 

A recent public flogging is documented in the records from the Oct. 31, 2006, U.S. National Transportation Safety Board public meeting on the final report of the Platinum Jet Challenger rejected takeoff and runway excursion accident at Teterboro (New Jersey,U.S.) Airport.  Capt. Robert L. Sumwalt III, NTSB vice chairman, spoke up:  “I’d like to speak as a board member who made a living for the last 30 years by flying airplanes.  Mr. Chairman, you commented earlier that you were somewhat incredulous that a professional crew would conduct this behavior.  Mr. Chairman, I would submit to you that this was not a professional flight crew. The behavior exhibited by this crew was not at all indicative of a professional flight crew.  Just because someone gets paid to fly airplanes does not mean that they are professional.

“TheUniversityofTexasfound that crews who intentionally deviate from standard operating procedures are almost twice as likely to commit additional errors with consequential results. In this case we saw where the crew failed to perform the weight and balance and it manifested itself in an accident.

 

“I strongly urge the piloting community to take the job seriously, and for the most part the piloting community does take it seriously. When we have an accident like this, not only does the crew let their passengers down, quite frankly, they let the entire profession down, and I take that very personally.

 

“I would urge the piloting community to follow procedures.  Do it right.  Do what you’re paid to do.  But I’d also like to point out that the operator has a responsibility to establish a safety culture. In this case we saw that there was a culture of non-compliance. There were widespread gaps, omissions, procedural deviations. A term I sometimes use is the ‘normalization of deviance’ where things are deviated from so often that they become the norm, and this appears to be the case here, where crews routinely were modifying — the board calls it modifying, I call it falsifying — weight and balance documents, just routinely, apparently.

 

“So I’d also like to send a message to the industry — it is vital for the industry to establish, and maintain a safety culture,” Sumwalt concluded.  That is a public flogging!

 

You may be interested in how the three examples I cited earlier turned out.

The seatbelt-less chief pilot was put on probation.  He continued to take shortcuts for several months until he was finally let go.  The rest of the organization took note and has since become highly professional in its performance.

 

Becky’s nemesis has been suspended from his flying duties.  More permanent action is pending.  This pilot’s future is not bright.

 

Unfortunately, a public flogging is not an option for the charter company president.  Two years after our incident in the Baron, he was scud-running a young family fromDenvertoAspen,Colorado.  There were no survivors.

 

PINCs are a disease.  Unchecked, they will infect your entire operation.  That infection can have extreme consequences.  Sadly, the price of PINCs is paid by innocent people.  Your antidote for PINCs is discipline.


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