Articles

    Managing Distractions in Aviation

    Author: Glenn Daley, ERHC Safety Chair

         What does a trip sheet, a smart phone, a tablet and a Blue Tooth paired headset have in common? Writing, texting or talking has never flown a helicopter. This concept was made real to me years ago when I was backing out of 6N5 on a 95-degree day near max gross weight. As I began the transition to forward flight and needed the pilot not flying to be monitoring the departure and making callouts, the other pilot felt it more important to make timely entries on the trip sheet. After we were in cruise happily on our way to HTO I asked the SIC if this was not a better time to attend to duties not directly involved with the safe operation of the helicopter? Several months later I was taxiing onto a very busy and crowded FBO ramp. As I was passing between two jets the SIC reached for the trip sheet to make a notation. I came to an abrupt stop and he said “what’s wrong”. I told him that nothing he was writing could be more important than helping to prevent contact with another aircraft or a fuel truck. These incidents are examples of “low tech” distractions that can easily be corrected with SOP’s and training.

         In our present-day cockpit’s, we have even more insidious distractions in the form of personal electronic devices such as smart phones and tablets. These are culturally based distractions that can even be described as addictions. Just take a moment and consider how much of our day is taken up by “screen time” How many people we pass on the street in a “heads down” posture. For some, these distractions prompt a Pavlovian response to the electronic stimuli that becomes reflexive. If a busy street is no place for “heads down” a crowded VFR corridor or route is certainly not either. We live in a world where electronic distractions are growing exponentially and are all around us throughout the day. For many of us electronic flight bags and flight planning applications such as Foreflight have become common place and indispensable. As with most good things, too much of a good thing can lead to problems. The time to familiarize yourself and to “play” with these devices is on the ground or in cruise when not the pilot flying. The simple fact is that non-aviation habits and norms have crept into our cockpits and it incumbent upon us to recognize and mitigate these effects before an accident rather than after. In research conducted by NASA on flight crew distractions. They have determined that pilots are vulnerable to errors and omissions when they attempt to multi-task. Cognitive research indicates that pilots are able to execute two tasks simultaneously only in limite circumstances, even if they can easily perform each task separately. Composing a text is an example of a task that requires active conscious processing and requires more than reflexive action or muscle memory. Flying a helicopter or driving a car is a largely automatic act. Our brains can handle either act singularly. Mixing an automatic act such as flying or driving with an active act such as texting will pose a challenge to the individual and in many cases results in a degradation of performance.

         The National Safety Council reports that cellphone use while driving leads to 1.6 millionaccidents each year. Texting while driving is estimated to cause 390,000 injuries each year. Currently 25% of automobile accidents are caused by texting while driving. Some studiessuggest that texting while driving can be three to four more times as hazardous than driving under the influence of alcohol. A well-functioning SMS (Safety Management System) allows us to be proactive and even predictive with regard to threats and hazards. If we do not translate this data into aviation operations we do so at our own peril.

         Distractions to maintenance and ground operations can be just as hazardous as operational distractions. Do you really want an aircraft technician performing a critical maintenance procedure to be distracted by a phone call or text? Do you want a line service person to be checking a tweet while fueling your aircraft? A few years ago, I was wing walking a helicopter from the hangar to the ramp in preparation for the days flying. To save time I called the FBO to order fuel while I was supposed to be paying attention to the blade tips clearance with other aircraft and the hangar door. After barely clearing the hangar door I realized that my full attention was not where it belonged, with the task at hand. The fuel call could have certainly waited for the two minutes it took to safely tow the helicopter to the ramp. Some operations have gone so far as to make the hangar deck a “no phone” zone unless the phone is required to photograph a part or communicate regarding a maintenance action.

         Two basic principles of an effective SMS are the identification of hazards and mitigating them once identified. I think we can all agree that there is a time and place for writing, talking and texting. Our challenge is to identify the phases of flight and ground operations where distractions must be mitigated. We must develop common sense policies and strategies to combat distraction. Some operators forbid the use of phones during any phase of flight. Others only allow their use during cruise, and in two pilot operations making sure someone is always “outside”.

         Hazards often cannot be eliminated but they sure can be mitigated. In addressing this problem I’m a realist. In our business timely communications with those we support and those that dispatch us are vital and cannot be dismissed. However, there is a great deal of room to apply some best practices. The next time you feel the urge to write, talk or text, ask yourself “is this the appropriate time and place for it”? If not just wait a few minutes until the distraction has a minimal impact on the safety of the flight or ground operation.

    Fly Smart, Fly Safe,
    Glenn

    Hazard Reporting System (HAZREP)

    Author: Glenn Daley, ERHC Safety Chair

         One of the most important and fundamental elements of a robust Safety Management System (SMS) is a clearly understandable and user-friendly Hazard Reporting System (HAZREP).

         The purpose of the HAZREP system is to identify hazards, evaluate their severity and mitigate them in a timely manner. This in turn allows us to isolate and deal with hazards rather than allowing them to reoccur. Every employee from the custodian to the department head should be familiar and comfortable with filing a HAZREP. They should be utilized for any condition, either ground or flight related, that poses a hazard to personnel or property. The mindset of, “if you see something, say something” should be fostered. Although HAZREP’s should never take the place of filling out an aircraft discrepancy, they can be used to supplement and enhance a squawk. The benefit of formally addressing hazards with a system is that it allows them to be evaluated for their severity, communicated with all employees and corrected as appropriate. An added benefit of the HAZREP system is that it empowers employees and demonstrates that their input is encouraged and taken seriously. This in turn promotes an active safety culture within your organization rather than just the appearance of giving “lip service” to safety. The SMS systematic approach also provides for trend analysis to determine if there are gaps or weaknesses in your SOP’s or processes that are resulting in similar type or recurring HAZREP’s.

         With regard to audits conducted of your flight department by external entities, some department managers feel the lack of hazard reports indicates a safe operation to the auditor. The opposite is actually true. What an auditor wants to see are a stream of HAZREP’s and how they were handled. This is evidence of a healthy SMS with “buy in” from staff and management.

         The method of filing a HAZREP can vary according to the level of sophistication your department desires. This can range from a form filed out and placed in the “HAZREP Box” to utilizing off the shelf customizable SMS software programs that allow you to file a HAZREP right from your smartphone or tablet. Whatever method is used, it should be user-friendly and not any more complicated than necessary. Although enough information should be solicited to properly evaluate the hazard, you want to make this process as painless as possible so members are not deterred form filing HAZREPS when needed. Most SMS software based HAZREP reporting tools are a good combination information gathering and simplicity. All hazard reporting systems should offer the reporter the opportunity of remaining anonymous, however it is usually better to know the reporter to gather additional information and to communicate actions taken and results.

         The next step is getting the report to the decision makers for evaluation and action. Usually any HAZREP filed should be sent immediately to the department/unit Safety Committee. This is typically comprised of: The Director of Safety, Chief Pilot, Director of Operations, Director of Maintenance and the department head. When using SMS software, the system can be set to automatically send these notifications. The committee should review the report and determine the severity of the HAZREP and set a “closure” time for the HAZREP as well as an action plan. The “Severity/Probability Matrix is a useful tool in determining this. The matrix determines the level of risk present by taking in to account how serious the hazard is and how likely is it to occur or reoccur. The figure below is an example:

         The “triaging” of potential hazards will help managers decide the speed in which an action plan must be deployed, and also determine the deadline for a HAZREP to be closed.  Depending on the severity of outcome posed by the hazard, this time frame may range from immediate action to 7 days, 30 days, or the next quarter.  In some cases, the committee may even choose to deem the hazard very low risk and simply accept it and monitor it as appropriate.

         The next step is diligent and timely communication with the reporter and the associated department in general. The reporter should be advised that the report has been received and is being evaluated by the Safety Committee. They should also be kept updated as to subsequent actions and decisions. This step is vital to give the reporter a sense that their report is being taken seriously and their input as a team member is valued. There is nothing more counterproductive to an SMS than for an employee to not receive feedback and in turn question the legitimacy of the entire system.

         The following are some actual HAZREP’s that I have dealt with over the years. When reading them, ask yourself how would you categorize them with regard to severity, how long would you allow to correct the hazard and what type of corrective action would you recommend?

    1. Dumpster on ramp adjacent to helicopter landing area left open causing trash to scatter from downwash causing a FOD hazard
    2. The crew lifejackets normally secured to the underneath of seats have repeatedly been found on aircraft floor unsecured. The elastic bands that secure them appear to have worn.
    3. Portable radios/cell phones worn on flight crew belts repeatedly are snagged by seatbelt buckle causing an egress hazard.
    4. Ground personnel walked in front of taxiing aircraft and was not visible in the dark until a near collision.
    5. Several S-76 inadvertent float deployments have occurred by former B-412 pilots. Possible negative habit transfer suspected.
    6. On two occasions tools discovered on transmission deck and in landing gear compartment during pilot preflight.
    7. Precautionary landing made due to partial power loss. Possible fuel contamination.
    8. On two occasions aircraft fuel cap left on aircraft step after fueling, lost during flight.
    9. Helicopter dolly surface slippery when wet due to years of oil/fuel soaking.
    10. Helicopter dolly’s black paint makes it difficult to see during night operations.
    11. Pitot/static system taped for aircraft washing. Preflight by crew discovered tape was never removed prior to putting aircraft back in service.

         As with most elements of a functioning SMS, the nuts and bolts of a HAZREP system are actually less complicated than initially perceived. The challenge stems from having a safety culture in place that encourages reports and appropriately acts on them; the net result being a safer operation both in the air and on the ground.

         Fly Smart, Fly Safe. Glenn