Head filled with clouds

Pilot mental health is back in the news again. Or at least it was yesterday. Briefly. For the cursory reader there were images served up of the appalling a sad GermanWings case. Resurrecting the deep horror and sadness of that event was unavoidable. Telegraph Article

Unwritten was the sense that pilots are unlike other human beings; that in some way pilots should be immune or hardened to the effects of life or emotions. Neutral robots. Operatives.

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Back to (Airbus) school

Back in the summer it began to feel like the right time to plan a change of direction in my career. I have two careers: I am a pilot, and I am (or was) a manager. Most recently I have been responsible for setting the strategy for BA’s cabin safety activities. That is to say, any activity behind the flight deck door which has a safety component.

It was a big job and a great deal needed doing. But I had a wonderful team, a very supportive set of peers (known as the Leadership Team or ‘LT’) and I had the pleasure to work with some superbly professional cabin crew colleagues.

But all good things… I needed to plan a gentle handover, bow out gracefully, and in a way that enabled the new manager to take on a new and functioning safety system which I had constructed. All lots of fun.

On the other side of the equation the pilot bit of my job is also fairly demanding. Being a Training Captain comes with the added pressure that your trainee expects – no, hopes and is entitled to – some morsels of information to help them through the training process. Discovering these requires empathy with the trainee; their background, their journey to this point. The thrilling reward for being a trainer is to be part of achievement. I remember certain trainers from different parts of my career. I remember their words, little nudges, pearls, flecks of gold punctuating a long and sometimes frustrating road.

After two and a half years splitting my professional attention between ‘the office’ and training the time had come to focus on being a trainer. Which brings me to a strange point in my career: My fifth (yes, fifth) initial type rating course on the little Airbus (A320 series). This time I’m on an outsourced course because we are in the middle of the biggest training year we have ever seen even for the might and scale of a big flag-carrier.

Each course has been different. Mainly because time does not stand still. I am a different and developing pilot, the course is always evolving. I know of few other pilots who have done quite so many initial courses on the same type (I am sure someone will write in, maybe we can develop a mission patch for this special club – feel free to draw some designs). But the objective of the course is the same. The end point is to create a pilot who is competent and able to efficiently operate the aircraft.

Getting to that point is the trick. It is all about layers. Well, layers and attitude. The course builds logically. First on your own experience (it assumes a baseline level of knowledge, the facilitator pitches the course pace and level), and then system-by-system the aircraft begins to take shape.

Attitude is important too. For the button-pushing, lever-wiggling, thrust-lever-shoving activist the pace might be too slow (I am writing from the heart here). The content might be too theoretical. The practical destination might seem very blurry. In the early days of the course there are plenty of opportunities to get frustrated. How does this relate to that? Dark areas, shadows hiding the not-yet-known leave gaps to fill. You need a resilience, a patience to look through these first days.

I am acutely aware that in a matter of months I will be training people on this aeroplane. They might be new captains, brand new pilots, experienced pilots joining from the military or from other airlines. So my attitude is to regard the layers and pace as a gift. To understand the way in which this complicated little jet comes together in the mind.

Against the wind

Against the wind

“…Sometimes doing almost nothing for a few seconds is the best course of action…”

Descent flight level one hundred”. As I spin the altitude selector I hear the harsh triple-bleat of the master caution. An orange light appears in front of my face. I glance across to the centre screen, the thrust levers slide backward. “Unscheduled stab trim” announces my colleague.

I shoot a glance back at the flight instruments, my hand resting lightly on the control wheel. I brush the autopilot disconnect with my thumb to remind myself where it is. Still there. Same as always. I begin to read out the autopilot modes to the other pilot. Everything is behaving normally – the aircraft is behaving predictably. No hills nearby. Not about to do anything dumb.

Sometimes doing almost nothing for a few seconds is the best course of action.

“OK, I’ll take the radio. QRH, Unscheduled stabiliser trim please”. Simon reaches to the side pocket and pulls the thick quick reference handbook out. He adjusts the overhead spotlight to brighten the soft glow of ambient cockpit lighting. My eyes flick down to the trim indicator… I’m sure that I can see it moving. The EICAS alert disappears for a second or two and then returns.

Under my hand the control wheel moves. The gentle bank begins a long sweep around the north-eastern corner of Moscow in the early hours of a summer morning. There is a half light ebbing through the windows. Five minutes ago the cabin crew called to tell us that they were finished and that they would sit down shortly. The weather radar sweeps silently through the yellow-grey gloom. A slight shudder passes through the airframe as the 767 pushes through blousey cumulus which have stopped out and lasted the night.

I watch the pitch symbol creep up the pitch scale. Pixels colliding. An imperceptible quickening in the rate. My interest changes from observer to actor: double click on the autopilot. A warning siren. Silenced. I tell Simon that I’m flying manually. The shiny surface of the control wheel pushes insistently into the heel of my hand. Much stronger than I anticipated. The nose of the aircraft bounces up a few degrees. I shove back. “Keep an eye on me here, Simon”. A firm push and I have the measure of the wounded bird. “I think I’d like to just level out here while you get that checklist done. What do you think?”

We glance at each other. The radio is alive again. “Speedbird two three five, contact one, one, niner decimal seven, maintain flight level one hundred on reaching”. We declare an emergency to get the spotlight on us. Simon negotiates a straight line in space. The controller is begrudging.

Our self-made gap in the workload means that we can methodically tick through each step without getting distracted by other demands. Metronomic and methodical. ‘Click, click’! Simon lifts two guarded switches near the thrust levers. More selections. With the left trim module out of the picture the problem seems to be cured. Mindful of language difficulties and our gently reducing fuel state we quickly wrap the checklist up and reboot our minds back into normal flying. Automation back in. What is the aircraft doing, where are we in space, has our ‘toolbox’ of capability been raided?

Did that pitch up unsettle or upend anyone in the cabin? Does the lost trim module make a difference to our landing? From beginning to end the whole process was probably less than three minutes. A simple failure had taxed our ability to prioritise the big ticket items, share some understanding of the plan then follow through on a plan.

Back to the navigation display. Still nothing much on the weather radar but between discussions with air traffic control and weather reports we know that the last few miles may be rough. Messing around dealing with the wayward trim module has left us high. I grip the speedbrake handle and ease the brakes into the airflow. I watch the vertical speed increase along with noise of air colliding with the panels on the wing.

Nothing you have just read actually happened. Well, not for real at any rate. I am about fifteen minutes in to my annual ‘Line Oriented Evaluation’ in a full motion ‘Level D’ simulator. It might as well be the real aircraft. LOE’s are no longer new: not every airline has the time or resources to create such a programme. The old regime was skills testing. Stick and rudder. Set pieces. Challenging in their own right but essentially a collection of unlikely and disconnected events strung together to meet the needs of a regulator.

LOE is intended to expose flight crews to realistic events in the controlled and assessible environment of the simulator. They are designed to offer up a scenario that might happen tomorrow. This includes all the medium-level trivia that has to be dealt with or scooped off to one side for a few moments as the situation demands.

Once a year – in addition to the set-piece skill test – each crew will have the opportunity to fly one of the three preset scenarios. This one starts at 20,000 feet in the descent. Some start on the parking gate, some in the cruise.

The common theme is to be found in the learning: structure wins every time. A good outcome is the happy outcome of joining what you know with what you can do. Of course both knowing and doing can all come to nothing if the ‘how’ isn’t up to much. Knowledge, skill and behaviour. Getting the ‘how’ right means that the speed, pace and thoroughness can all be ramped up or down depending on the event type. Thoroughness? Yup – ultimately everything in aviation is against a timer of sorts. Even if it is just the size of your fuel tank. As Bob Seager said: “Deadlines and commitments/what to leave in?/what to leave out?”

So what did I learn today? As usual, the video took no prisoners. I took away that I am pretty good at sharing relevant information – and at bringing suggestions and options out of my colleague. I could probably take a bit more time when it comes to rounding off the tail end of some non-normal procedures. Overall, I’m happy that the best skill that I learned was how to steal good ideas from other talented aviators and pretend that they were mine.




Can Safety Culture Help Profits?

This is a picture of the Service Manager's car. It must be very inconvenient for him to give up his car for the next four days? You might be wondering why I have shown you a picture of a 5 series? What could this possibly have to do with airlines, aircraft and all the usual stuff that I tweet about?


I am fairly certain that the 5 series is the best saloon car on the planet. This one is very nice. Just the right amount of toys, nice colour combination, 8 speed auto. The technology is fantastic. Even the iDrive is intuitive enough to allow me to use it without ending up in a ditch.

So here's a thing. I have just been on the receiving end of a lengthy error chain. My car ended up with wrong-sized tyres fitted. Completely wrong. The service centre didn't spot it, I did. And when I told them, they tried to convince me that I was mistaken. The experience has been interesting to say the least. I thought I would use it as a parable to illustrate how safety and brand are interlinked. If you want to know how having a good set of safety 'behaviours' can affect a company's bottom line, read on.

Wind the clock back three days. I am trundling to work on the A30. My BMW 1 Series is just about the nicest all-round car I have owned (and I have owned LOTS of cars, especially BMWs). It is comfortable, drives nicely, doesn't cost a fortune to run, looks equally at home with the seats down driving to the tip as it does pulling up outside a posh hotel. It is relevant to this story that BMWs are pitched as 'premium products'. In buying a BMW I, like many others, have spent more money buying a product which I perceive to be 'better' than cheaper alternatives. The Ultimate Driving Machine. Maybe. It is undoubtedly a magnificent bit of production engineering. Maybe I'm a dullard for paying the extra cash? I am no different from anyone who buys anything but the absolute cheapest of any product.

BONG. The central display turns orange and an image of a car appears. A little 'caret' points at the orange car's left rear wheel. BONG BONG. The display changes again. A bit more urgent. Pointers at all the wheels, the multifunction screen changes. Not a happy car. I pull into a service station a little way up the road. Runflat tyres: the left rear looks pretty normal to be honest. I know from having received a nail through a tyre on my Mini Cooper S after only 8 miles of ownership that it is difficult to see a flat. It takes a lot of air. Reset the system, drive the remaining 3 miles to work. When I get out of the car I can hear the air escaping.

Being a cautious kind of guy I took out tyre insurance (after my Mini Adventure!) so I call the dealership; we discuss my tyre insurance. The gentleman needed to know the tyre size which I thought was odd. I trudged back out to the car and crouched down in the pouring rain to read out the tyre size and speed rating. Apparently the tyre was 'unusual'. This seemed weird enough for me to question – “they are just the tyres that the standard car comes fitted with, that seems odd?” I began to doubt his competence just a tiny bit. I asked to him to order two tyres because I dislike having a spread of wear depths across the car. Good news, the tyres would arrive the next day. I had a diary full of meetings and appointments so clearing out a morning was a major hassle. I drove home very carefully after failing to get any more air into the tyre. Wet, slow, squirmy in places, but safe.

“…the charm thing…”

I sat in the service reception early the next morning: cafe style. A service 'representative' does the charm thing. There's free coffee, Sky News and a big board full of other BMWs that you might want to buy. I deliberately distance myself from this board. Dangerous. Last time I did a similar thing I almost ended up owning a bright orange 1M, pen quivering over the final documentation. Premium service style gets you coming back for more… if it's done well.

An hour later, car done, all paid up (insurance didn't cover it because I had gone under 3mm in one tread position) I scooted out to the car in yet more rain. I looked at the tyres briefly. They looked quite – well – big. Bulbous was the word that popped into my mind (I thought of Lord Melchit “Crevice, now that's a dirty word”). I needed to get on the road; a new team member to meet and an appointment with the CAA was ticking ever closer.

“…the car felt peculiar…”

The car felt peculiar on the way in to work. Peculiar enough for it to play on my mind. I'd never noticed it sound so 'crashy' over bumps. It seemed to sit differently on the road. Ever so slight. But cars always feel different with fresh tyres on, don't they? I was in work early the next day. Lots to do and an early getaway needed to make good an evening out. I had parked in the open. Walking towards the car in the daylight it looked all wrong. As I approached it side on it just looked funny (this non-specific recognition is really important in specialist or expert error-trapping).

For once it wasn't raining, so I stood a few feet away sipping my oh-so-middle-class-mocha staring at my oh-so-middle-management car whilst airliners roared overhead. Spot the difference: each tyre had a very different profile, no protective edge-beading. The sidewall section was totally different to the wheels on the front. I carefully read the read the lettering on the sidewalls. The tyres were even called something different – some weird eco-name thing. That was enough for me. I rang the service centre again. The call progressed like this:

767 Gear

Got these in a 245/35?

Irritating menu, wait, nice receptionist, holding music, service 'representative'. Me: “Hello, look, I might be going completely mad but I think that you put the wrong sized tyre on my car”. Rep: “Riiiiiiight. Do you know what size they are?”. At this point I was starting to think about how BMW manage their customer data. They only fitted them yesterday, presumably he could just look that kind of thing up? I had probably had 10 different interactions with BMW over a 48 hour period and in most of them I had been forced to start from the beginning of the story. Me: “I was hoping you could check the tyres that you fitted against the spec for my car? These just look way too big”. Rep: “They are probably bigger at the back than the front”. OK… now this is getting silly. At this point it should have been pretty simple to check one bit of data against another bit of data. We went back and forth a bit. Lord knows what he was checking. I even Googled “118d M Sport tyre size” and got the answer I needed inside 10 seconds. But BMW might know better than Google, right? They are the experts.

90 minutes of to-ing and fro-ing confirmed what I had found in a single Google search. Wrong tyres, far too big. The process of fobbing off began: The tyres will be fine… Maybe I could come in sometime next week? Wait a moment. I had been out to the car and studied the placard on the door frame. Nowhere was this tyre size listed as acceptable for the car. There were plenty of other sizes but not this one. I queried it again. “I really need to understand if the car is drivable in this condition?”.

“Yes, it's fine”. Really? What about the wheel arches? Clearances? Speedometer accuracy? What about my insurance? Yes, it will all be fine. I stopped the guy and ran him through my tyre insurance scenario. One tread position was measured at 2mm. No tyre insurance. I suspected that an insurer would take a similar view if I was involved in an accident… sorry but your car is fitted with a peculiar tyre config. That's an undeclared modification – we won't pay.

My evening was ebbing away. In all probability I would miss out on the restaurant and maybe miss the start of the performance. As far as I could see this problem was still mine – it didn't belong to BMW. Yet. My final questions were to ask if they could provide me with a car for the weekend and what would happen to prevent a similar incident happening again. Extraordinarily, he said that they didn't have any cars (odd for a car dealership) and that they would 'look into' the incident. Unsatisfactory. A whiff of BS, too. He had spoken to the 'Master Technician' about it. My mind wandered to a chap in pristine overalls sitting cross-legged on a Snap-On toolbox.

Manager on the phone. Nice chap. I felt sorry for him really. For the first time I was talking with someone who genuinely seemed to understand that this had all gone wrong. “When I looked at that tyre size I knew instantly they were wrong for your car, sir”. We had a nice chat until he started talking about how the tyre company was actually a supplier and not part of their organisation. This winds me up. I'm a customer, I don't care how the business is structured.

So here I am. His car is parked neatly in front of my house. Very handy it is too. If you trade on a reputation for quality and excellence you have to deliver it: even when mistakes happen. A lot of organisations work on the assumption that 'better' is a 100% record of perfection. It might even be achievable in some cases. But in complex safety-related environments it is likely that error or failure will occur eventually. For me the error was spoiling my trip into the Big Smoke. For an airline customer it could be lots more serious.

Making a Responsive Safety Culture

So what is the key to making a responsive safety culture and rescuing the situation? Is it even worth it?

To answer the second question first: yes it is! Look at this situation. There's a large, difficult-to-quantify cost when you compare making the same error (ordering the wrong tyres) and intervening early with what actually happened. There is still a price for the error. The early intervention option would be mildly frustrating to the customer, it might cost the price of a cab to Heathrow, or the use of a demo car for a day. It comes with the upside that I wouldn't be wondering what else the mechanic has not checked. I wouldn't be thinking of using another dealership in future. Nor would I be wondering if the Audi dealership were any better (they are not, by the way, I can confirm). I wouldn't be writing this and you wouldn't be reading it. None of this would happen.

So, if there is a way of trapping errors more effectively the result is a happier customer, less money spent on the problem and improved customer retention.

First question second: A responsive safety culture? It may come as a surprise that the answer can be found in the quality of individuals that your organisation employs. Their aptitude, experience, preparation and engagement all has a bearing on the end result. Let's pick this event apart… almost like it was an aircraft incident.

Recognising that 'Something is Up'

Malcolm Gladwell (@gladwell) in his book 'Outliers' talks about the key to expert behaviour being the '10,000 hour rule'. Gary Klein (@KleInsight) in 'Sources of Power' tells us about 'Fire Ground Commanders' who had a 'sixth sense' or highly advanced intuition which tweaks something deep inside their skulls when it is time to get the hell out of that house. Kahnemann is his fantastic book 'Thinking Fast and Slow' disagrees with Klein postulating that “…intuition is just recognition…” but the glue that binds all three is that the human brain is extraordinarily capable of gathering information from a variety of indicators. The subconscious brain is always pulling data in. The brain is even capable of piecing together bits of other, similar scenarios to apply experiential learning to a previously unseen set of parameters.

For example, I know nothing about tyres, or 1 Series running gear geometry but I applied my knowledge of what my car normally looked like and my skills learned through years of flying air tests and acceptance flight to know that something wasn't quite right.

The service manager applied his specialist knowledge and found a probable answer in moments “…they were wrong for your car…” because he has spent years around BMWs.

So what about missed recognition opportunities? When the service guy set the order up, the tyres were 'special order'. He told me that. I even queried it. It's pretty strange for a company to not carry a consumable item in its regular inventory for a popular product. The technician who sent my car on its way must have seen how tight the tyre looked in the wheel arch. I wonder whether his internal monologue tweaked his experience? Being sensitive enough to slow down a little when something doesn't quite feel right is a skill. You have to train it into people – especially in a world full of normal. High density shorthaul operations are like this: especially in the Airbus. Everything ticks along beautifully. Another ILS, another loadsheet, another datalink clearance, another………

Permission is Easier to Grant than Forgiveness

Strange though it may sound, you usually have to give your team 'permission' to act on their intuition. How this happens is bespoke to specific organisations – it can be a difficult thing to describe. The difference or oddness that you have recognised might be something… or it might be nothing. If it's nothing, then that might delay, disrupt, annoy. All for – well – nothing. You might even be seen as 'risk averse' or 'overly cautious'. It's a balance, of course, but letting your teams know that it is OK to call a halt when something doesn't seen right is the bedrock to developing a healthy culture.

Mitigation is OK – Sometimes


Committing to early mitigation might save a ton of trouble later on

This fell out of favour in some organisational cultures for a while. Sorting stuff out when things had gone wrong became the marker of failure. Riffing around the daily disaster wasn't the way to do business. What was needed was better technology, better systemisation and improved process. All of that is correct but if you ignore likely failure modes then your 'system' becomes a 1 or a 0. It either works or it doesn't and it begins to lose the ability to self-heal. That is not a recipe for resilience. You can see this characteristic in this event: “…it's OK to drive the car…” reads like 'press on', or 'it's OK, I've got it'. As an instructor and when debriefing events I see pilots persisting with automation modes that have become inappropriate as the circumstances have changed (maybe you were flying a FLCH descent but now you are really above the glidepath?). Knowing when to switch from the planned, polished product to the dirty old rescue vessel takes practise too.

Owning the Problem

The remedy has to belong to someone. If the problem occurs on my watch then I have to be the person that fixes the problem. That means that I have to admit that the problem exists. It might be embarrassing and I might even want to blame it on some external factor. None of that washes. The success of the outcome depends on someone seizing hold of the issue and steering it to a conclusion. If the moment of commitment is missed then a spiral develops. Perhaps on my first call the Rep could have said “drive the car straight here. It's our mistake. I'll have a car waiting for you and we will call you when your vehicle is fixed”? Instead we stuck with 'bring it in next week'. You take the risk on your insurance etc. We will treat you like a normal customer in the systematised conveyor.

In the airline world I hear it a lot: ATC really screwed us for mileage, or even the slightly more Freudian “the aircraft was unstable at 1000 feet” as if it had developed a consciousness. The joy of the aviation environment is that these interactions happen all the time. The dynamism is what makes any job fun and fulfilling. Solving problems and making stuff 'right' requires sensitivity and flexibility. Get it right and you will take your customers with you as well as head off more unnecessary costs. Get it wrong and you'll not even have a chance to say 'sorry' a second time.


The automation paradox | Making training relevant

I stole the title, but the picture is all mine. Let's talk a little about what is going on in that picture: Right there is a very fine pilot. She is methodical, skilled, excellent at influencing her colleagues when needed, great at fitting into the team just about right (the trickiest of tasks for the second in command). Just left of centre you can see a white, plastic lever. This lever is poking up. It is surrounded by two others. These are the three autopilot engage/disengage levers. The 'Center' autopilot is engaged… or at least that's what it looks like from here.

That's one of my favourite pictures to date. It reminds me what a great view we had during that approach: A nice flight down from Edinburgh. Great weather, no aircraft defects or complication. We had briefed the approach and I offered my FO the option of a manually flown approach (remember, this is BA, so the landing is mine but the approach is flown by the other pilot). We discussed some of the threats and how we might mitigate them.

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Lessons from the Staines Trident

A little after 4pm on the 18th June 1972 Trident G-ARPI started its takeoff roll at Heathrow. About three minutes later “Papa India” lay shattered in a small field between the A30 and a housing estate just outside the southwestern boundary of the airport. Everyone on board was either dead or dying.



The accident drew out the best and worst in people: a small boy ran to alert a nurse who was playing near to the site of the crash. She called the emergency services who later squabbled over whose territory the aircraft had crashed on. Policemen risked themselves to look for survivors. Cars stopped on the A30 so that their occupants could stand on the edge of the road and watch the broken remains and rescue effort in the field below.

The gloomy pallor of industrial unrest enveloped the disaster. Bitter disputes were commonplace in 1970's Britain. The nation was riven with post-austerity anger and division and BEA was no different. Lurching from one disagreement to another about pay, status, mergers, aircraft, conditions. You name it, there was disagreement about it and 19th June was planned to be a strike day. This ensured that 'Papa India' was full of passengers anxious to avoid the chaos of the next few days.

Airlines had ceased to be the preserve of the super-rich and super-famous. By '72 getting on an airliner was almost normal. Airlines responded to demand by adding flights, fleet size and destinations. Pilots were needed to feed this demand. The Trident was crewed by three pilots and BEA were actively recruiting young men to train at the colleges in either Oxford or Hamble to fill these seats.

In the cockpit were three operating pilots: Captain Stanley Key. A veteran, a Route Check Captain and – according to the report – an extremely accomplished pilot. He was assisted by two young Hamble graduates: S/O Jeremy Keighley was seated next to Key performing copilot duties, behind them Simon Ticehurst performed third pilot duties.

Popularised reports and documentaries over decades have singled out Captain Stanley Key as the main protagonist in the accident. I remember the accident being discussed during CRM courses. Key bore the brunt: Books, articles, internet posts all rounded on Key's personality coupled with his latent heart condition. The outburst in the crew room, the puerile slogans scrawled by others on parts of the flight deck, his reputation as a 'stickler' for procedures and his brusque manner all pointed in the direction of Key as the root cause.

On the 18th June this year I drove down the A30 on my way to work at our training centre. The lights turned to red and I pulled to a halt at the traffic lights by the Staines junction. I glanced, into the field and decided to read the accident report with twenty-first century eyes. I needed to know whether Key really was an ogre. Was it his domineering personality which caused the 'droops' to be retracted too early? Did both Copilots remain silent, aware of their fate but paralysed by fear?

A few things are certain: the event marked a sea change in aircraft accident investigation and the understanding of human emotions in aircraft events. One section entitled “Human Factors” probably started that concept the instant it was published.

One frustrating element was missing for the investigation: the cockpit voice recorder. Eyed suspiciously by pilots who were already nervous about flight data analysis, recorders were available on other types but not on the Trident. The question of professional privacy kept them away from some flight decks but Papa India changed all that. Flight Data for the accident was available but it told a confusing story. A litany of extraordinary error spewed out amongst the electronic confusion. There were more questions than answers. The public demanded to know what was going on in the flight decks of their airliners. Eavesdropping on the pilots' conversations was the only way to know for certain.

The report

I thumbed through the report. The tone is fatherly, patrician, complex with more than a whiff of the judiciary about it. I was transported back to that era. I read it front to back a few times, sketching down notes and questions before being drawn back to the 'argument'. In my memory there was an arc drawn between the moment in the crew room and the crash itself. I was surprised that the whole thing is described in just two paragraphs. Key was challenged about his efforts to garner support against the upcoming strike. He was against the strike (I had assumed he supported it) and the outburst ended with him apologising to his inquisitor and leading him away by the arm: Not really the actions of a monster with no recognition of his own behaviour. Could a couple of seconds of disagreement really be the true root cause?

The more I read the more I realised the subtext of the investigation; it was a defence of the then-new system for training 'cadet pilots'. The report was a guarded defence of both of the copilots and with it the whole cadet scheme. There was clearly contemporary criticism directed at a programme which could place pilots on board a complex jet airliner with just 225 hours inked into the pages of their logbook. This criticism presumably came from pilots who had been sent off to war decades previously with far less experience and nothing like the structured training or focused understanding of their role.

Poor design

I was interested in the balance of the report. It occasionally made sweeping generalisations to close down elements of an argument. Hawker-Siddley's design was quickly exonerated by virtue of their response to a number of similar events and their actions. The report chooses to avoid questioning how other manufacturers design their flap and slat systems. I found this absolutely extraordinary. At the root of this accident was an error of selection and the design of the aircraft made such an error possible. A cursory study of contemporary designs reveals that Boeing combined trailing edge and leading edge selections into a single lever. The 707 – designed in the 50s – had this feature as did all of the subsequent 7-series models.

Ergonomically this design was poor: Look how close the levers are in my picture above. Modern analysis would look at the likelihood of an error occurring and the severity of it happening. Such an appalling design simply wouldn't get off the drawing board today. Frankly, this design is the most tragic part of the crash. Contemporary designers had foreseen an issue such as this and engineered it out. No amount of weepy-eyed sentimentality or patriotic duty would cause me to make excuses for this awful oversight. Complex aircraft are not made better by being made more dangerous and trickier. The 767 that I fly is a great aircraft precisely because it is so faithful in its flying qualities. The A320, the 737, the 777: they didn't become market leaders because they were like taking a tiger for a visit to a primary school.

Training signals

Keighley's training record leapt off the page at me: He was “slow to learn” and would “require careful watching”. Perhaps most significantly he was “slow to react in an emergency” and “lacked initiative”. To my modern, training manager brain this told me two things: That it was doubtful that Keighley had met the required standard on the course, and it was probable that the course and its instructors did not meet his needs as a trainee.

Did this mean he was not suitable to fly the Trident? Absolutely not. Trainees learn at different rates. Trainees like different styles. The system back then was something of a monotheism: it was trainer-centric too. My boss (Chief Pilot!) went through Hamble in 1972 – he proudly described his instructor report from that time which angrily states that he would “…never be an airline pilot…”. Today we have a different philosophy. Start from where the trainee is, give them a reason to progress, adapt your instructional style to get them there. It's a contract, a partnership between trainee, instructor and training organisation. We don't send people to the line with a flea in their ear about “needing careful watching”. The trainee can do absolutely nothing with that information. It gives him neither purpose, nor direction. If you wanted to send someone into a job feeling underconfident and adrift, that was the way to do it.

Loss of control

Severe Loss of control accidents are usually characterised by a lack of recognition of the problem. By their nature, loss of control events are usually a surprise to the crew. Often the pilots continue to force their perception of what should be happening in front of what actually is occurring. When I am teaching, I describe the process of fixing the issue as a mental “gear change”. The brain needs to neatly slot from “flying to Brussels” mode to “Save the aircraft” mode.

Not easy: for starters you have to convince yourself that a massive error or mistake has occurred. You might even be responsible for it. Pilots are not good with admitting fault. Initial training is all about success. It is all about correctness, rectitude, getting it spot on. The accident ends up being just a tragic comment on human nature – hoping for success despite the evidence.

Air France 447 was precisely the same: if you are an airline pilot back stick usually means 'up'. Forward stick usually means 'down'. It doesn't really matter if you are flying an Airbus, a Boeing or a Beechcraft. For your whole career that has been true. With the wing stalling forward stick is sanctuary; it helps turn the wing back into a beautiful and artful shape for teasing lift from air instead of a lump of draggy metal.

The report describes how stalling is taught: clean, approach configuration with some flap out and then again with some thrust on. Crucially the exercise was – and usually still is – conducted as a theoretical exercise. If you really stall an airliner nobody ever says to you “…ok, shortly we will explore the stalling characteristics…”. So, if the difference between success and failure is recognition, we really need to put the manoeuvre into some sort of context.

The cadet pilot programme

This is still topical. In the wake of the Colgan Air crash in 2009 the FAA now mandate that an airline First Officer has 1500 hours. This was an emotional response and an oversimplification of the issue at stake: Colgan had rest, employment and social issues at its heart. The same recognition issues that put Papa India into the ground put Air France and Colgan down too. Experience alone is no guarantee of competence.

The Hamble 225 hour route was the first of its kind. Highly structured, this programme assessed suitability and trained in competence from early on. The product, however, was – and still is – a green and limited individual. Competent and ripe for development but lacking outright experience. The theory is sound: aviation is diverse and complex. Why spend time flying around gaining skills in an aircraft type which is not relevant when you can pass on core skills and consolidate on an airliner?

The report stops short of discussing organisational themes: what about the extra skills and demands placed on your captains? Was a robust system in place for identifying the need for further support and monitoring progress? The debate will rage on: Multi-crew licences are here and the same old arguments rattle around. The key is that today's aircraft commander needs to understand that the capability and limitations of his crew change daily and with the environment.

Organisations need to refocus on providing the skills for commanders to coach, for first officers to accept feedback and for the whole culture to incorporate personal responsibility for development an learning. A 1500 hour pilot will suffer skills atrophy – if he ever even had them. A 225 hour pilot may have the skills and the aptitude but find himself in an organisation which does not provide support for development. A 10,000 hour pilot may find himself unable to intervene because he lacks the culutral skills or organisational support to act decisively when needed.

What I really learned…

…was that we are still learning the same lessons. We are even having the same arguments. Was Key's behaviour or heart problem to blame? I suspect that it was little more than a media sideshow; a great opportunity to dramatise a complex and convoluted event. More positively, the Papa India report assured me that I am on the right track: my vision for training systems, support, investigation and pilot management are sound. But it also reminded me that if I ever stop learning or enquiring then I should give it all up


Pitts Special | Classroom

^ My own picture from http://www.airliners.net

There's a neat clunk when you lock the large Perspex canopy of the Pitts. Ratcheting down the harness forces your thighs into the seat completes the circuit: you are now an aircraft. Looking from stumpy, rounded wingtip to wingtip I mentally capture the point where the horizon cuts the engine cowling. I have to do this every time I fly. One day I hope to burn this simple image into my brain but right now I know that it's best to place a recent copy in the very front of my thoughts.

It is such a simple machine; it's skeleton is at my fingertips if I want to touch it. A bare soul. Raw. Straight. This mellow autumn light makes the yellow paintwork shine. It should really be highly polished metal because what you get out of a Pitts is what you put in: perfect return of energy. No secrets exist between you because this little biplane is a quiet confidant, a therapist. It has seen it all. It's a mirror held up close to your abilities. Sometimes kind, sometimes flattering. Always brutally honest.

If you prime the engine just right you might just catch some combustion on the first few blades: a hard blatt from the stubby exhausts, the airframe twists and shudders with the building torque, I let the wheels roll an inch or two before squeezing on the brakes. As I move out to the runway I fishtail for some visibility. Just a little rhombus of clear space edged by fuselage, wing and strut is all you get:

Lesson one from the Pitts – sometimes you only get a glimpse of what you need. Slowly, deliberately you have to map out your pathway to the runway. It's an exercise in careful attention and just a little dose of faith.

As I push the power on the controls stiffen as they brace against the quickening air. Every fibre and strand of the aircraft begins to come alive. Tail up taking on the sky: Like flexing muscle the aerodynamics begin to force the little bird straight. Busy movements. Tiny taps with my feet set wide apart against the fuselage walls, a slight tug over the top of that bump and I sense the wheels break away from the ground. Holding it down low speed is rapidly building through 100 mph and beyond as the elevator pushes at my palm.

A glance up and right into the cool blue sky, back down to the airspeed, I register the position of the needle but not the value. A nudge on the controls. No special movements but the beautiful result is an arcing, climb to the right, preposterous in both steepness and grace. Wings level I suck the last few seconds of excitement back into my mind, the altitude giving me space to think again.

My usual rolling warm up isn't going well. One way, then the other. I keep leaving myself off centre. Sometimes the roll dishes a little. Then there's too much push. Lesson two: you have to be honest with yourself. As the nose pivots on the horizon I can feel the aileron pushing into the airflow, the pressure returned along the control rods, through the stick and into my wrist and forearm. Stop. Missed the wings-level point again. Roll right. Worse. Another to the right. I stop in the inverted for fun, reference is just about right. A glance at the altimeter. Big needle stationary. A tiny flick on the oil pressure and steady again. I pause to take in the view, chin stretched up slightly enjoying the perverse pull of gravity. Hampshire villages pepper the landscape. Long shadows stretch west, it's a weekday and cars are moving slowly in the back lanes.

Right way up, I bank and track the nose left and right across the horizon. A little steeper, I feel the the forces build as the wing tucks into the turn. The bottom wing draws a small circle around a cluster of farm outbuildings. It looks like I'm alone here. Wings level, keeping a straightish road on my right. A tough pull to level, pause, pull again hard and feel the energy fall away as the nose comes through the vertical line. My brain takes a snap at that point, my hands and feet move to balance torque and aerodynamics.

I rock my head back to find my line. There's a window of gentle lightness at the top of the loop before the crescendoing din of air over the blood pounding in my ears. This one feels good. But I'm not consistent today, flashes of good with some ragged edges. There's that second lesson again. To get better you need to be honest. I know that I need to reflect: part of my learning style so it's time to head home.

Lesson three: brilliance in some areas is often associated with compromise in others. Landing the Pitts is a combination of compromises. A bit of give and take. Stablised along a skewed line towards the threshold I move the nose just enough to see my touchdown point. Just enough throttle to balance the drag watching the runway end swell. The final movement doesn't give much leeway. I remove the slip which releases the drag, straighten up plus just a touch of left foot, slip the power down to idle and work the nose into the landing attitude. I hunt for the picture I recorded earlier. Hold. Patiently wait until the wheels brush the ground.

The same busy taps that kept us straight on takeoff come in useful again as I mentally sketch in the runway edges blotted out by struts and aluminium. Lesson four: If people tell you something is difficult it may just be because they weren't doing it right in the first place. Whilst landing the Pitts was never straightforward it was one of the most consistent, and rewarding aircraft to land I've ever flown. Before I'd flown it people told me it was impossible to land well – a 100 mph shopping trolley. They were wrong.

The Pitts is parked on the concrete slab between the hangars. A little later I walk back to the aircraft, flight suit zipped up, ready to fly. Canopy locked. I pass the straps over my shoulders. The high metallic tick of the harness ratchet is the only sound. I pause. Stretch my toes out on the rudder pedals and wiggle to settle in properly to the seat. I stare at the fuel gauge on the top of the cowling. This is not feeling right. I use the silence to check around my head. Nope. Not quite right today. The last and final lesson for the morning. There was nothing to gain from another trip. If your head and your heart aren't together, you probably can't do your best work.

I wheel the aircraft back into her slot in the hangar. I take extra time putting the cover back on, folding the tapes up and placing them neatly under the straps. Arranging the streamer on the pitot tube. A few small streaks of oil from the cowl need wiping off. I point my finger at the 'horizon spot' at the edge of the cowling and quietly tell myself “about there”. I'll never remember it. I will remember these five lessons though: glimpse where you want to go and work out how to get there, be honest with yourself if you want to keep improving, to see brilliance you'll probably have to accept compromise, don't believe it's impossible and, there's no shame in coming back another day. Keep your head and your heart together.

Thank you Curtis Pitts. That's quite a machine you made. Everything I learned in that little biplane is useful on a daily basis: the lessons are valid in so many fields.