Structure and Discipline Are Critical, but the Procedures Have to Be Sensible

Section: Operations

Structure and discipline are critical, but the procedures have to be sensible.

Jan. 24, 2006, was a spectacularly clear winter day in Southern California. John "Jack" Francis and Andy Garratt were crewing a Citation V that departed Hailey Airport in Sun Valley, Idaho, bound for McClellan-Palomar Airport in Carlsbad, Calif. Aboard were Frank Jellinek Jr., recently retired chairman of Fisher Scientific and father of two children, along with Janet Shafran, mother of four. It was going to be just a brief stay in the San Diego area. Jellinek's father, Frank Sr., lived in the vicinity. Everyone planned to return to Sun Valley that afternoon.

The Santa Ana winds had abated at Palomar Airport. METARs reported five- to six-knot winds out of the east or northeast at Palomar and it was a chilly 40oF early that morning. The control tower had not yet opened, so Francis and Garratt planned an approach to Runway 24, which is the most commonly used runway. They began their descent for the airport about 30 minutes prior to arrival.

The published runway length for landing is 4,600 feet, measured from the PAPI touchdown point to the end of the overrun. The landing reference speed for a Citation V at max landing weight is 107 KIAS, according to Cessna's Flight Planning Guide. Its FAR Part 25 landing distance would have been 2,815 feet, assuming a maximum landing weight arrival, a 500-foot field elevation and 10oC outside air temperature and no wind conditions. Palomar's actual field elevation is 331 feet msl.

The initial descent profile was far too shallow for a stabilized, straight-in approach to Runway 24. The aircraft was just 17 miles northeast of the airport when it passed through 10,000 feet, according to the track records available through FlightAware.com. Eight miles away from the airport, its ground speed was 300-plus knots and it had not yet descended through 5,000 feet, according to the same source. Two miles and 900 feet above the runway, the ground speed was in excess of 200 knots -- 93 knots greater than the highest published landing reference speed for the airplane.

Witnesses reported the aircraft "came across the runway threshold at a speed significantly higher than they had observed with other aircraft of the same or similar model" and that it "touched down more than 1,500 down the runway," according to NTSB.

The pilots deployed thrust reversers in an effort to decelerate the aircraft, but when it became apparent they couldn't stop on the runway that remained, the crew stowed the reversers and attempted a go-around.

By then, it was too late. The aircraft was too slow to get airborne and it hurtled through the overrun at speed. Its landing gear hit the localizer antenna platform and the left wingtip caught an access ladder to the platform. The airplane plummeted down the steep hill beyond the runway, crashed into a self-storage building 80 feet below and burst into flames. Both pilots and both passengers were killed in the inferno.

The NTSB still is investigating the accident and only a preliminary report is available. The Safety Board has yet to assign a primary cause for the accident, but it appears there was nothing wrong with the airplane.

A Seemingly Never-Ending Problem

Peruse the NTSB records and you'll find similar mishaps involving both general aviation and commercial aircraft going back forever. And all too often there was nothing wrong with the airplane.

With ever more stringent aircraft certification and airworthiness requirements going into effect, lack of having a Standard Operating Procedures structure and/or breakdowns in crew discipline accounts for an increasing percentage of accidents.

Robert Sumwalt, the NTSB's vice chairman, doesn't mince words about the severity of human error as the probable cause of such incidents. Speaking at the August 2007 Air Line Pilots Association Air Safety and Security Forum in Washington, D.C., the former airline captain and business aviation flight department manager, said, "What we are talking about here is professionalism... . While we are talking about professionalism, don't confuse getting paid to fly with being a professional pilot.... Professionalism has absolutely nothing to do with the size of a paycheck or the size of your airplane."

Sumwalt pointed to recent high-profile fatal accidents involving regional aircraft, operated by Pinnacle Airlines, Corporate Airlines d/b/a American Connection and Comair, in which the NTSB cited pilots' "unprofessional behavior" as the probable cause. Line Operation Safety Audits indicate that crews who deviate from SOPs are three times more likely to "commit additional errors with consequential results."

It's this "normalization of deviance" to which some crews become accustomed that's so problematic. The crews simply redefine the way they do business in the front office and "eventually fail to see their actions as being deviations," Sumwalt said.

He just as appropriately could have been talking about the Citation V accident at Palomar Airport.

Deviations from SOPs erode safety margins and potentially result in violations, then incidents and finally fatal accidents. The probability of having an accident becomes a matter of when and not if without such discipline.

In contrast, flight operations that have well-defined procedures and well-disciplined pilots who adhere to them have the highest safety margins and safety records. Notable examples are U.S. military aviation divisions, major airlines and virtually all large corporate flight departments.

This process doesn't start with line pilots, explained Edward "Ted" Mendenhall, retired head of Gulfstream Aerospace's flight operations and current coordinator for the Flight Safety Foundation's corporate flight operations quality assurance program. "Some 'old heads' just don't want it. They may have 20 pages of SOPs, but the manual is just collecting dust in a closet.

"Cockpit discipline really has to come from the top. It has to start with an organization's management. They have to want it." This is the foundation for the entire company's safety culture.

Formal Structure and Standards for Flight Departments

The importance of defining comprehensive SOPs for each phase of flight is recognized by ICAO. The NTSB notes that the nonexistence