It’s breakfast. Switzerland. They’ve spelled my name wrong; I let it go uncorrected. It’s half eight in the morning somewhere else. My clothes don’t quite match my surroundings and my shoes don’t quite match my clothes. The February rain is likely falling as snow up on the hills but down here it’s the kind of drizzly rain that makes people walk fast and straight-legged with their shoulders drawn in. Tick-tock, the minutes slide by. Continue reading
Converting to a new aircraft is fun because it is a licence to be a learner for a while. In January I completed my training back to the Airbus A320 family of aircraft. The flying is fun but the baby Airbus is overly complicated by an obsession with unachievable precision and theory. Continue reading
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.
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
“…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.
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:
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
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.
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.