A deadly impression throughout a coaching flight involving two skilled pilots prompts Adrian Park to think about the connection between guidelines, procedures, compliance and human efficiency. 

The phrases that spell out guidelines and procedures are lifeless marks on a web page till they’re embodied and lived out. It is a fact as historic as Plato who mentioned phrases have, ‘The looks of knowledge however not the truth’. Due to this fact, I imagine CASA’s newest security slogan is an efficient one: ‘Security is in your palms’. 

However after all, the truth is, whether or not we be frontline practitioner, boardroom supervisor or federal regulator, all of us carry round 2 variations of ourselves: what we may usefully name our ‘finest’ and ‘worst’ variations. 

A second of self-reflection is all it takes to substantiate the existence of our worst model. And the scary factor is we’re not speaking about Jekyll and Hyde, or the werewolf. Your worst self isn’t some furry monster that howls on the moon: it’s you at 90 per cent of optimum. You continue to look and sound the identical, it’s possible you’ll even really feel the identical, however you lack the sting. 

We may all testify about how this diminished self emerges on the again of stress, fatigue, distraction, workload, sickness, complacency, battle and numerous different performance-sapping circumstances. Certain, more often than not our worst model isn’t the agent of an accident however, with solely a slight tweaking of circumstance, it simply may need been. 

An necessary query then arises: how can security guidelines and security procedures account for each the worst and the most effective variations of ourselves, with out changing into hopelessly congested or gargantuan? 

They’re among the many most demanding a helicopter pilot can expertise – we used to name them ‘black gap’ approaches.

I’ve spent the final 6 years making an attempt to reply this query. I’ve approached it by analysing 50 years’ price of accident investigations from these publicly accessible on the Australian Transport Security Bureau (ATSB) web site. Collectively, from the tragedies of actual accidents (1968–2021), I’ve recognized what I name 10 purple guidelines. 

The ‘purple’ refers back to the approach the principles are, in a way, written in blood and the way in which they signify the important rules by which aviation professionals function safely or, of their absence, don’t. 

Time doesn’t allow full remedy of the ten however probably the most influential are:

• situational consciousness – understanding what is going on
• judgement – understanding how to reply
• proficiency – being ready to make the precise response

I name these the royal 3 as a result of collectively, in over 50 years of Australian aviation investigations, they so evidently govern almost all profitable flights and, of their lack, are implicated in almost all accidents. These are ‘royal’ security guidelines as a result of they’re the principles that rule all of them. 

There are various elaborate purposes of the purple guidelines however the easiest and a very powerful is that this: if we wish guidelines and procedures to empower the most effective security variations of ourselves, we’d like guidelines and procedures that generate glorious situational consciousness, nice judgement and excessive proficiency. 

Right into a black gap

That is emphasised by a just lately launched ATSB accident investigation. It concerned an evening method by an EC135 helicopter to a bulk provider in near-zero illumination close to Port Hedland. 

As anybody who has flown these approaches will let you know, they’re among the many most demanding a helicopter pilot can expertise – we used to name them ‘black gap’ approaches. It is because the darkness of the sky, mixed with the darkness of a nonetheless ocean, conspires to deliver concerning the ominous absence of any helpful horizonal or terrestrial cues with which to guage up from down, quick from sluggish, descent from ascent.

Within the merged darkness of sky and ocean, the method should be manually flown relying virtually completely upon the devices. To conduct a protected method, the pilot should always learn the plane velocity, charge of descent, altitude, distance from the ship and so forth, to construct a psychological image, whereas monitoring the devices.

The pilot has to make judgements about that psychological image and modify the controls because the plane descends nearer to the unseen ship and the unforgiving ocean. Within the phrases of the Australian poet Clive James that is flight in ‘a token world whose import is immense.’ And, since it’s a helicopter and, most of the time, the night time winds change markedly by the descent, the correcting and adjusting are virtually steady. 

In brief, such approaches demand a excessive diploma of situational consciousness, excessive proficiency and sound decision-making – they demand the workforce’s finest model of themselves. And, for many operations, that is what the method will get. The requisite proficiency is out there, situational consciousness is maintained, sound judgements are made and one other profitable flight is logged. 

However, on the night time of 14 March 2018 close to Port Hedland, the confluence of 4 vital components considerably compromised the workforce’s ‘A sport’ as they carried out marine pilot switch coaching. 

First, the pilot beneath supervision was getting again into flying after 7 years away from dark-night marine pilot operations and was considerably completely different to the one the pilot had simply left. The earlier 7 years of flying had been in a single-engine helicopter with a lot much less complexity and automation than the twin-engine EC135. 

Second, a good coaching schedule meant the primary night time flight was not throughout the congenial setting of an airfield however the demanding setting of a darkish ocean method to a bulk provider. 

Third, the identical tight coaching schedule meant each pilots have been experiencing the results of fatigue and, for the pilot beneath supervision, this was to a performance-degrading diploma. 

Lastly, design components meant the trainer was sitting on the left facet of a single-pilot configured helicopter with out simple reference to key efficiency devices. To see such devices, the trainer needed to look throughout to the right-hand pilot’s instrument cluster. 

Underneath these situations, the flight was primed for the emergence of the workforce’s worst model, as it will for any workforce within the grip of comparable situations. This shortly grew to become evident within the first method. 

Having established the plane on remaining descent and having decoupled the ‘higher’ modes of the autopilot, the pilot beneath supervision was having issue ‘flying the road’. On the identical time, the trainer, with out instrumentation on that facet of the cockpit, was having issue readily detecting the difficulties of the pilot beneath supervision. 

The web outcome for the primary method was a too steep descent. And, including to the problem, was an rising crosswind because the plane descended. This meant the 6 levels of proper drift at peak become almost 20 levels of proper drift on the decrease ranges. At about 500 toes, realising the plane was descending at 900 ft/min (almost double the traditional charge of descent), the pilot started a go-around. 

Midway round what would usually be a stage base flip, the airspeed had decayed to 30 knots and the descent charge was rising in direction of a lethal 1800 ft/min.

A go-around in circumstances like this isn’t a uncommon factor. As mentioned, these approaches are among the many most demanding a helicopter pilot can expertise. The positive strategy to get higher is to practise.

Due to this fact, the pilot beneath supervision accomplished the go-around, turned the plane onto downwind at 1,100 toes and ready for the subsequent method – and it was right here the decisive second occurred. 

As an alternative of the downwind altitude being maintained both manually or by utilising altitude-hold, the plane started an unintended and unmonitored descent, first at 500 ft/min, then 800 ft/min, and the descent continued rising into the bottom flip. 

Midway round what would usually be a stage base flip, the airspeed had decayed to 30 knots and the descent charge was rising in direction of a lethal 1800 ft/min. That this went undetected is perhaps shocking however, on such nights over water and at slower airspeeds, it’s virtually inconceivable to discern by really feel or sound the distinction between 200 ft/min and 2000 ft/min. 

The one indications are a couple of altering numbers amongst many different numbers on the first flight show. Usually, when human efficiency is at its finest, these numbers are learn and acted on however, on that night time close to Port Hedland, with a cognitively loaded, distracted and fatigued crew, the instrument readings have been seen however not perceived. 

This state of imperception continued till the trainer, trying throughout the cockpit and seeing the descent however not absolutely appreciating how dire it was, referred to as for a rise of energy. The pilot beneath supervision may need heard the decision however, nonetheless mentally catching up with the plane, didn’t reply. The plane continued to quickly descend and, at 300 toes, regular cockpit sounds have been disrupted by ‘verify altitude, verify altitude’ from the radar-altimeter annunciator.

Midway round base, the tinny voice from the annunciator was unwelcome. It caught the eye of the trainer who took management and started to use energy however not sufficient – the speed of descent decreased a mere 300 ft/min, from 1800 to 1300 ft/min. 

With rather more inertia than utilized energy, the outcome was inevitable. Just a few seconds later, the plane hit the water and rolled inverted, to be held in place the other way up by inflated floats. The teacher managed to flee the plane by a damaged windshield however
the pilot tragically didn’t. 

Who’re you actually?

It’s simple when studying an accident report like this to inadvertently undertaking our greatest model into the occasion. However that is to erroneously evaluate our greatest model with another person’s worst model. To be honest, and sensible, we might do much better to undertaking our worst model into the accident as a result of the reality is, our worst model is just one misplaced night time’s sleep or one lengthy absence from flying or one excessively-stressed second, away. 

Accident investigations like Port Hedland will be seen as ‘what if’ biographies of ourselves on our worst night time in our worst state. That’s what I’ve seen within the 50 years’ price of accidents I’ve studied. However I’ve additionally seen one thing else that far outweighs the accidents: actually tens of hundreds of incident-free flights. 

Due to this fact, the logical conclusion is, within the nice majority of flights we’re bringing our A sport and the most effective model of ourselves to the complexities and calls for of aviation. Which brings us again to our unique query: how can guidelines and procedures take care of each the worst and the most effective variations of ourselves, particularly once we proceed to hold round our accident-primed worst model. 

The necessary reply, and the one with which I’ll conclude, is that guidelines and procedures, to be authentically protected, should be people-empowering. 

Of all the principles and procedures we write, in the event that they don’t tangibly empower the qualities of fantastic situational consciousness, nice judgement and excessive proficiency – the principles and procedures is perhaps ‘protected’ by title however they won’t be protected by nature. 

Guidelines and procedures, to be authentically protected, should be people-empowering. 

The Port Hedland crew had many guidelines and procedures however such guidelines and procedures may solely, sarcastically sufficient, be enacted by a workforce with the three qualities talked about. Due to this fact, guidelines and procedures mustn’t ever congest, complicate or confuse the people on the centre of aviation who – whether or not they be frontline practitioner, boardroom supervisor or federal regulator – are referred to as to persistently reply and adapt to the sophisticated security calls for of the actual world. 

After 28 years flying, in addition to 6 on security analysis for a PhD, I may say many sophisticated issues about security guidelines and security procedures. However one easy factor strikes true: it’s not guidelines and procedures that primarily make us protected – it’s empowered individuals. 

Plato’s knowledge is an efficient place to return to conclude: for security’s sake, within the writing of many phrases – whether or not expositions, rules or insurance policies – let the correct quantity of phrases deliver people-empowering knowledge, not its sophisticated look. Then we are going to actually be capable to say to our aviation groups – security is in your empowered palms.