Wednesday, May 27, 2015

Top Ten List- Goodbye David Letterman

Last week, a well-known late night TV talk show host, David Letterman*, retired after over 20 years.  His last show was reportedly watched by 13.7 million people. 

In this post, I'll tip my cap a bit to The Late Show in publishing a TOP TEN list.  It comes from my good friend, Jon Egeler at Mission Safety International

For longer than Mr. Letterman has been behind his mic, MSI has done an outstanding job at calling mission aviation agencies to the highest level of safety and vigilance in their commitment to serve worldwide efforts to express the love of our Creator God.  

In 2014, they reviewed their data from recent years and created the MSI Top Ten items that lead to mission aviation mishaps.  Here, listed in reverse order, is their list (drum roll please):  


This has become a growing concern, especially with the transition to using JetA-1. Not only are we having to learn new procedures and ways to ensure the quality of the fuel, but microbial growth and contamination is a big concern in the hot and humid environments where many missionary aviation programs operate. In addition, many programs are now using both JetA-1 and AvGas, and there have been way too many close calls and even serious incidents when aircraft have been mis-fueled with the wrong fuel. This has been especially true with fuel stored in remote locations. 


As the costs of operating aircraft have risen dramatically, especially with the increasing use of turbine equipment, it is becoming apparent that the old way of using donated aircraft and having flight and maintenance personnel on support is not sufficient. Every flight program we have visited in the past 5 years is under financial duress, often at an extreme level. This results in cutting corners so as to cut costs, and becomes very risky. The most tempting things to cut are training, safety programs, and main-tenance. However, any airline can tell you that if you start cutting there, the end is not far away. If we are to survive long term, and do things well, we must find new ways to cover the costs of operations. 


Another item that seems to be way too prevalent is in the area of aircraft discrepancies. Most organizations have a formal system of recording aircraft discrepancies that occur during operation. However, there seems to be almost universal hesitance to use the formal system. Usually, the reason given as to why something was not written up in the formal log is a fear of grounding the aircraft. Most commonly, there is a lack of understanding of the system, and an informal “unofficial” system exists to pass the discrepancies to maintenance. Unfortunately, the informal system is very imperfect and not robust, and we are finding many unresolved serious discrepancies in our audits. 


This is common in service industries and organizations. The oft stated “we are here to meet the needs” just doesn’t cut it. Goals and purpose need to be well-defined, stated clearly, and understood by the whole team. If they are not, it becomes very difficult or impossible to set priorities, decide how to best use resources, and evaluate your performance. Without the focus that clear goals provide, we tend to become overly busy, stretched thin, and try to do too many things. This results in high stress, burn-out, poor performance, low standards, and little margin. These all increase risks dramatically. 


This seems to be a prevalent problem, as we replace vacancies in personnel positions with whoever is available or convenient. In missions, we have lots of movement, with people being reassigned or going on furlough or home assignment on a regular basis. Too often, there is not much of a master personnel plan, or a strategy to teach and train future managers and leaders. This results in poorly run operations, which increases risk considerably. Poor management has very long-reaching implications, including not setting proper priorities, poor use of resources, not setting and maintaining high standards, improper supervision, and potentially increased turnover rates. 


We are seeing an increase in people not conforming to or complying with established procedures. Sometimes this is due to a lack of understanding of why the procedures exist (a training failure). Sometimes (thankfully more rarely) it is because the individual simply doesn’t agree or want to do it that way. Combined with a lack of accountability, this can be disastrous, as we repeat the same mistakes others have made, with tragic results. The lack of accountability is quite common in missionary aviation, where we often are operating with only one crew member, and supervisors are rarely on-site. 


Defined as landing approaches that do not meet the criteria of being on the proper airspeed, glideslope, descent rate, lined up with the runway, and configured properly for landing at a pre-determined point on the approach. If the approach does not meet the criteria by the pre-determined point, a go-around is initiated. Unstable approaches introduce so many variables that the likelihood of a hard landing or runway excursion or overrun increases exponentially. The vast majority of missionary aviation accidents occur on landing, and based on the data we have been able to gather, a high percentage of those happened after an unstable approach. 


This is also a natural human tendency that will occur if we allow it. More and more we are seeing pilots and mechanics who are satisfied with “good enough”, and only trying to meet the minimum legal standards. Rather than setting very high personal standards, they are letting the standards be set for them, and doing just enough to get by. Striving for perfection in what you do, and achieving excellence as a result, is a foreign concept. This often leads to complacency. Complacency is the state of reduced attention or vigilance that often occurs when people get over confident or underestimate risks. It is most common when someone has done something successfully many times, and they begin to let their guard down. It can also occur when someone does not fully appreciate the risks, perhaps due to inexperience or lack of knowledge. Complacency poses a great risk because it reduces our ability to successfully handle the unexpected, and we often end up doing the wrong thing. 


This is a common human condition, if we allow it. It occurs when we allow ourselves to be distracted or unfocused,and we lose sight of what the top priorities should be. We stop paying attention to detail, and things slip through the cracks. It can also occur when we become complacent or relax too much, and therefore is often closely related to the next category. This category is a high risk in missionary aviation because we operate in a demanding environment with many variables that can easily distract us. In addition, we are often operating with not much extra margin, so the consequences are severe. 

...and the number one greatest concern in mission aviation is...

#1: Inadequate Airstrip Conditions:

The vast majority of missionary aviation accidents occur on landing, and airstrip/airfield conditions are a very strong causal or contributing factor in a great number of them. This category can be referring to the runway surface conditions, obstacles and clear areas, approaches, markings, charts, incursions and security. As we operate bigger and more expensive equipment, the consequences of even minor incidents has risen dramatically, and we must do a better job of evaluating and proactively eliminating or managing these risks. 

Thank you, MSI, for collecting this data and bringing it to our attention!  It's a great thing that the majority of mission aviation agencies are members of MSI and are regularly audited by Jon and his team.  Our audit, in Gabon, just happened in September of last year.  We'll report more from that soon.

*Little known fact:  In 1993, David Letterman was invited to the marriage of Alace Catherine Morris and Stephen Craig Straw.  There was no response to the RSVP.  Pretty rude, if you asked me.

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