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ATFB 147

Making change happen

CHIRP provides a vital safety net when normal channels don’t deliver the results

As I write this editorial we’re approaching halfway through the year so I thought it would be useful to give an idea of the main themes reported to CHIRP in these first 6 months. The chart shows the associated top-10 Key Issues reported to us across the Air Transport sector and, for those who are interested in the breakdown of each Key Issue, the sundial chart at the end of this editorial shows the principle sub-issues for each (the Key Issues are in the internal wheel and their associated sub-issues are in the outer wheel).

Each report can be ascribed more than one Key Issue or sub-issue and so care needs to be taken in interpreting the chart.  In this respect, ‘Duty’ and ‘Fatigue’ are often synonymous within individual reports but, collectively, it is telling that these 2 issues continue to represent the bulk of concerns raised to CHIRP by a long margin. Often, we can’t publish these reports or interact with the companies ourselves on specific details due to confidentiality issues but rest assured that CHIRP has represented their content to the CAA to indicate our concerns that it appears to us that some companies are rostering some duties at the top end of the FTL spectrum.

Concern about ‘Pressures/Goals’ is indicative of too much being asked of crews within the resources available (both time and crewing levels). Overt pressure (such as bonus payments for departing on time) or implied pressure (such as leading questions being asked as to the use of Commander’s Discretion) can put crews in an unenviable situation where safety might be compromised as they try to cut corners to satisfy their masters for fear of negative consequences.  Companies clearly need to run as efficiently as they can in these uncertain times but, as James Reason pointed out, efficiency and safety can sometimes be in competition with each other and so all of us need to know when to raise the red flag and stop when things appear to be compromising safety. Easier said than done, it sometimes takes real courage to ‘call it’ but those companies with an enlightened ‘Just Culture’ management philosophy will take such calls to heart and step back to review what has been going on. Sometimes it can feel like nothing is resulting from reporting but change will only occur if reports are made rather than keeping it to yourself and grumbling; only with sufficient reporting evidence will company safety management systems respond, and be required to explain what they are doing about it by their regulatory oversight team.

Of the remaining issues, internal communications, relationship management (aka ‘trust’) and company policies /organisation all hint at the same problem. If things are communicated in a transparent and inclusive manner then most people will go the extra mile to achieve the aim. If new policies, procedures or imperatives are not adequately communicated, people feel disconnected from the management, undervalued and disinclined to lean into the task. Middle-management are often blamed for lack of commitment to their subordinate workforces as they try to enact company policies, and they’re often the squeezed layer in the Senior-Middle-Workforce sandwich, but communication (and trust) is a two-way requirement that is not just a transactional process of sending and receiving messages, but also one of interpreting and negotiating meanings – and the meaning you intend is not necessarily the one that the recipient takes away with them. Furthermore, communication and trust is always complicated by an almost infinite number of factors such as expectations, attitude, prejudice, history, values and beliefs, moods, likes and dislikes, etc.

The bottom-line? CHIRP provides a vital safety net as another route to promote change when the normal channels of reporting aren’t delivering results, you don’t feel able to report through company systems, and for collecting reports with safety concerns that did not meet the threshold for normal reporting and would otherwise have gone unwritten. We rely on you to report Human Factors related aviation safety concerns to us so that we can both help in their resolution and highlight relevant issues to others. Reporting is easy by using either our website portal or our App (scan the appropriate QR code shown or search for ‘CHIRP Aviation’ – avoiding the birdsong apps that come up if you just search for CHIRP and the legacy version that we are about to remove!). In our reporting portal you’ll be presented with a series of fields to complete, of which you fill in as much as you feel is relevant – not every field is mandatory, but the more information you can give us the better. Although you’ll need to enter your email address to get access to the portal, none of your details are shared outside CHIRP, and we have our own independent secure database and IT systems to ensure confidentiality.

Steve Forward, Director Aviation

  • FC5253

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    Incorrect hold entry due to chart confusion
    Incorrect hold entry due to chart confusion

    Initial Report

    On the descent into EGWU (Northolt) on the NUGRA 1H arrival we were told to expect holding for 10 minutes at Bovingdon (BNN). It was a very high workload phase of flight for us because not only where we constantly being vectored, we were also going in and out of very bumpy rain showers. The instruction given was just a few minutes prior to reaching BNN and was as follows: “Expect holding at BNN, 10-minute delay”.

    Right away my co-captain diverted his attention to trying to find the published holding at BNN and showed me the Jeppesen chart for the NUGRA 1H. It was NOT immediately clear what the published holding pattern was. I told him to query approach about what they wanted us to do because we were quickly approaching BNN. I wondered if maybe they wanted us to hold on the missed approach hold from the EGWU ILS25 because it was off a radial from BNN. My co-captain’s query was “Do you want us to hold on the missed approach holding pattern off of BNN?” The reply we got was hold as published. At this point we should have asked for vectors because we couldn’t find the published holding pattern at BNN. Instead, we entered a hold south with 1-minute legs, right hand circuits. Approach asked us if we had entered holding to which we replied yes. They must have realized we entered the wrong hold because the next instructions were vectors for a 10 minute delay.

    When we got on the ground, I realized something had gone wrong and opted to call the EGWU Tower to get clarification on the holding. After a few minutes of discussion, I realized my mistake; the Jeppesen Chart had a bubble note indicating published hold for BNN but it was not printed close to point of the hold. Because of the way our charts are displayed in the cockpit you must find the bubble note in a different portion of the screen (slew the view to a different portion of the chart) and it was missed. I asked my co-captain if he had ever seen these notes before on other charts and he had not. Unfortunately, I knew about this subtle change but missed it because of the increasing workload. In the end this was good reminder that if you are unsure of a clearance not to accept it until you are positive you know the instructions. The airspace was very busy but asking for a vector hold would have prevented this incorrect hold entry.

    CHIRP Comment

    Ordinarily, crews inbound to Northolt do not hold at BNN and are given a vector for the approach so being asked to hold would have been unexpected. Furthermore, the Jeppesen charts for the procedure do indeed have the published hold pattern someway offset from the BNN location on the chart and so there is some sympathy for the crew (see screenshot with highlight arrow).  However, as part of their arrival brief, the crew should have made sure they knew what any potential hold procedure would be as they approached BNN and, if not clear what to do when instructed to hold, they should have asked the controller for more information or requested radar vectors.  Equally, although controllers were justified in assuming that the pilots would understood what was required when they were issued an instruction and did not query it, the controller could have asked whether the crew knew what was expected of them given that this was not a normal routing. Ultimately, the approach plate gives a warning ‘Do not proceed beyond BNN VOR without ATC clearance’ and so the crew ought to have conducted a self-briefing about what contingencies might result once they arrived at BNN in case they were not cleared to proceed beyond.

  • ATC834

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    Degradation of core safety values
    Degradation of core safety values

    Initial Report

    This is going to prove a very difficult issue to articulate as our unit safety performance remains very good and is arguably better than previous years. Unfortunately this is far from the whole picture. Management decisions and a seaming refusal to invest in core systems is simply poking more holes in our Swiss cheese.

    Danger Areas

    A report following a danger area (DA) infringement many, many years ago highlighted the need to improve our DA notification process and associated radar mapping – it should have resulted in the implementation of a system called LARA [Local And sub-Regional Airspace management support system]. In its infancy, iFacts, our area controlling tool, was supposed to provide conflict support to DA’s. It seems implementation during iFacts was removed due cost and time constraints. LARA was expected and then seemingly parked in favour of our next system DPER [Deployment Point EnRoute]. This was due into AC [Area Control] in 2019 I believe and is significantly over budget and late. It is likely any DA conflict detection may well be missing when and if it is ever deployed. ‘Operational’ date now unknown.

    Our Supplementary Information Screen (SIS) is based on 1980/90’s software and is hugely labour intensive to adjust, it is done manually by a human and there are regular mistakes. Attempts have been made to tighten up procedures but there are so many different parties invested from Swanwick Military, Plymouth Military, Qinetic, Swanwick Civil, MABCC or L4M that I’m not sure we have improved things. Over the last three years we have suffered a significant number of danger area infringements for a variety of reasons but ultimately they can be aligned with the problems above. Human error, poor interpretation of information, poor display of information and lack of tools support. As traffic levels return, so will the mistakes I believe. We will only be lucky so many times before a serious incident occurs.

    There is no sign of LARA, no sign of the DPER software that’s already overdue, not that the latter would have significantly improved things to the best of my knowledge. Senior NATS management believe it will, but my operational colleagues believe the system is significantly ‘dumber’ than required to improve the current issues. It is an embarrassing mess.

    Removal of simulator emergency training.

    Over my [numerous] years I have performed [many of] the roles associated with our ART / TRUCE activities.  We have improved the range of emergencies trained and also the training of staff behind the scenes who perform pseudo pilot and controller tasks BUT the actual simulator has in my opinion deteriorated year on year. It is, I believe, no longer fit for purpose. We do not resource it appropriately and therefore cannot simulate the full extent of our emergency catalogue and system fall-back scenarios properly. To make matters worse, simulator training has been suspended for the 2023-24 season. All newly valid controllers (of which we now have an increasing number) are expected to undertake simulator ART every year for the first 3 years, I believe this is agreed with the regulator. This year’s suspension is still awaiting regulator sign off I believe but management are pushing ahead regardless of the overwhelmingly negative response they have received from the operational controllers and competency teams.

    We learnt a lot from our handling of BA5390 in June 1990 [G-BJRT explosive decompression with commander partially sucked out of cockpit], but we are rapidly undoing all of the good work we did in the years afterwards to improve the standards of our emergency training. The holes in this particular Swiss Cheese are also growing in my opinion and I have grave concerns about our ability to handle a significant event, fortunately they are very, very rare but this probably exacerbates the problem really.

    Finally, the operation at Swanwick seems to be being ignored in many other areas, which impacts morale and dictates operational performance to a degree. Our temporary ops room which we should have vacated in 2019 is a disgrace. Trip hazards from worn out carpet tiles, Radar arms that no longer meet DSE rules and regs, a permanently faulty ops room door that impacts our fire and security, inadequate TEMPORARY rest and kitchen facilities. The list goes on but…. the amount of space here limits further explanation.

    CHIRP Comment

    Notwithstanding the NATS comments above about ongoing expected improvements, the sub-optimal single-point of display of Danger Area information to controllers does not at present appear to be robust enough. CHIRP has previously commented on this following a similar report about Danger Area handling that we received about 2 years ago (ATC820) and that we had hitherto published in our Air Transport FEEDBACK Edition 140 newsletter (Report 4).  After considerable correspondence with NATS at the time, we were advised that the LARA tool was unlikely to be fielded until late 2023 and that the NATS senior leadership had commissioned a ‘Feasibility & Options’ paper to identify potential avenues for improved Danger Area information systems that might provide mitigations in the interim. It seems that we are not much further down the road with Danger Area handling and we welcome NATS’ further comments above about “reviewing other alternatives that, whilst not as good as the full DPER integrated solution, may offer an interim step to provide further support to our controllers.”

    With regard to emergencies training and the use of the simulator, it has to be acknowledged that the simulator has also to be prioritised for other activities such as airspace changes and system refreshes. As a result, there is undoubtedly a high demand for simulator time, and NATS has to prioritise its use versus the various risks to operations from all of the demands. But, in this respect, it seems that the simulator is under-resourced to a point that, where possible, all courses or mandatory training are being shifted to other means. NATS say they are pro-actively managing simulator use, and, on the face of it, the move from a single simulator day per year to more regular focused simulator and computer-based training sessions may offer some positive opportunities.

    Notwithstanding, CHIRP is told that the licensing-requirement days for simulator emergency training[1] have already been shortened due to lack of simulator staff from 4hrs of simulator time and an hour or two in the classroom facilitating discussion of hot topics, to 2hrs of simulator time (shared amongst 4-6 people so approximately 1hr in the hot-seat) and 4 hours in the classroom (normally hosted by a simulator assistant not a competency examiner as was the case in past). Whereas controllers used to run through five to six different emergency scenarios as tactical controllers during these days, now they are likely handling only one or two. Therefore, because the simulator day is now not offered annually to experienced controllers, they may practise only a couple of emergencies every 3 years. CHIRP believes that the reporter’s concerns about the simulator’s fitness for purpose and availability need to be addressed, and it is hoped that this report might be a catalyst for doing so.

    Finally, many of these issues and NATS’ responses hint at potential, or at least perceived, sub-optimal communication between the management and the workforce. CHIRP lacks sufficient insight into the NATS internal communications channels to make comment ourselves, but there may be a case for reviewing their efficacy, especially with regard to internal company newsletters or associated electronic channels for example.

    [1] A simulator every year after validation until 3 years qualified, then once every 3 years (but able to attend annually in place of the alternative annual recurrent training options if desired).

  • FC5254

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    Altitude deviation
    Altitude deviation

    Initial Report

    Climbing through FL200 for FL210 with the autopilot engaged, we received an altitude alert indicating that we were 1000’ away from our level off. This was audibly acknowledged in the cockpit by both the PM and PF. At this point it is my belief that there was movement of the speed bug knob or heading bug knob which has a similar tactile feel and appearance as the altitude selector knob in this model of Falcon jet. This resulted in disabling the automatic altitude level-off function of the autopilot; upon realization of the altitude error, immediate corrective action was taken by the PF and a vector was given by ATC.

    Apologies were made to ATC for the error. During the post flight debrief we discussed maintaining extra vigilance that the autopilot levels off at the correct altitude and that when changes are made moving flight guidance panel knobs, there is a corresponding indication on the Primary Flight Display.

    CHIRP Comment

    The fundamental factor in this incident was to remember that in this aircraft type at least, changes to some system settings would disable the automatic level-off function and so great care is required in doing so, especially when close to a critical event such as levelling off. It’s easy in the heat of the moment to mistakenly move the wrong knob so, as the reporter infers, always check that the autopilot is still engaged in the expected mode, and responding, whenever making any changes to parameter settings.

  • FC5250

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    Stable Approach Criteria changed without notifying pilots
    Stable Approach Criteria changed without notifying pilots

    Initial Report

    At [Airline] we operate using e-manuals which are updated on a daily basis electronically. Periodically we are notified [by notification system] of significant change to operating policy, prior to specific manual upgrades. I attended a recent simulator check and, during the briefing, was informed by the trainer that the Stable Approach Criteria policy had been updated. This was quite a surprise as this is one of the most important elements of our operation, and you would expect this to come via formal notice. The trainer did not know exactly when the change occurred but suggested it was several months ago already. We have now received formal notification of the policy change; however, I know of at least one pilot who unknowingly breached the new policy during this period.

    Many of us are concerned at the speed and volume that manual updates occur – the majority of them are small, insignificant and often irrelevant to role. We often only discover policy change through discussions on the flight deck.  This also raises the question as to how a change to a fundamental element of our operating policy has slipped through without the chief technical or training pilot deciding / remembering / considering to promulgate formally.

    CHIRP Comment

    CHIRP has commented before on the need to have robust policies for a defined cycle of regular changes to documents rather than a series of ad hoc updates.  The frequency of such updates depends on the nature of the change (routine, urgent, administrative etc) and, in this case, it seems that rational decisions about how to incorporate the changes were unfortunately derailed by an administrative error that led to them not being properly promulgated. One of the purposes of simulator checks is to refresh crews on recent changes and so this fail-safe activity worked in this case but it is concerning that some crews may have unintentionally been operating in contravention to their OM-A because they weren’t aware of the changes.

    CHIRP is heartened to see that the company is investigating why the administrative error was made, and also why the failure to promulgate was not evident. A change as significant as a revised Stable Approach Policy would hopefully have been considered within the company SMS processes and this should have highlighted the importance of robust promulgation channels. In any such investigations, it’s important to distinguish between errors and mistakes: in ‘Just Culture’ safety terms, ‘mistakes’ are symptomatic of people misunderstanding the task and potentially requiring further guidance or training, whilst ‘errors’ indicate that there are systemic problems that induce people to do the wrong thing. It behoves all organisations to mitigate as many systemic inadequacies as possible so that errors are reduced; in the circumstances of this report, this may identify safeguards that could be introduced to ensure that critical documentation is not lost in the system but properly highlighted to those who use it.

  • FC5240

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    Online learning
    Online learning

    Initial Report

    In 2018/9 the company were instructed by the CAA to roster a day of online learning to reflect the time that pilots were spending outside of their duty days completing tech quizzes, pre learning for simulator, aircrew notices etc. Once that happened the company added more study material to be completed before simulator sessions and took the SEP course entirely online (they did roster a day every other year for this item). The required pre reading for the simulator now covers 35 items.

    All the courses that I used to attend a classroom to take part in are now done online in our own time and we are rostered a day of every year and a day off every other year to reflect this workload in our own time. At least we were. The company have now taken to rostering the online learning day in chunks, either before or after a duty. They have been challenged by the BALPA, their response is that it complies with the CAA request to record the time we spend doing online learning. My issue with this is that this is a cynical ploy to comply with the CAA requirements ignoring the spirit.

    I was rostered an online learning block of 3 hours after an 8 hour duty. I was given 90 minutes to get home and then 3 hours online learning. This fails to take into account the fact that after a total of 9½ hours out of the house, a flight in bad weather at both ends and a commute in bad weather both ways the last thing I feel able to do is sit down and study. In the event I actually contacted crewing and asked them to put me down as fatigued for the online learning part of my duty. Whilst the company may well be complying with CAA requirements, rostering the time in blocks like this either before or after a duty is wholly inappropriate. It is nothing more than a paper exercise to make sure that pilots are available for the maximum number of days flying, over the years the time spent on courses has been pared down to the absolute minimum. A case of the company wanting to have its cake and eat it?

    CHIRP Comment

    The reporter’s contention is that online learning is now rostered in chunks that are not compatible with other duties. As the company comment notes, such training is not part of FDP calculations and rostering them for a specific duty period is simply a device to ensure that the time spent is accounted for as a duty in its own right and therefore included within basic pay etc as appropriate. Although it was assigned a specific date/time, it did not mean that the training had to be conducted at those times, and the activity could be done during reserve or standby for example, or whenever suited people best. Be that as it may, this was not clear to the reporter (and perhaps others), and so there is a case for the company explicitly stating within its training guidance that the timing of such online training is flexible provided it is completed within a predetermined date as applicable.

  • FC5241/FC5251

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    Absence policy
    Absence policy

    Initial Report

    FC5241 Report Text: [Company] have released a disciplinary process for pilots reporting sick 3 times in 12 rolling months. I believe this will have a negative impact on the company’s safety. I have already experienced flying with people of weren’t fit to fly but have reported for duty as to avoid disciplinary meetings. This causes great concern for the airlines safety.

    FC5251 Report Text: My Company has recently introduced a new Wellness & Absence policy. The policy is draconian and coercive.

    CHIRP Comment

    Absence management within the airline industry is an issue of topical interest at CHIRP at the moment and we have been engaging with the CAA and a number of airlines in this respect. CHIRP thinks that the issue of flight/cabin crew absence management is something that needs to be reviewed across the industry in order to recognise that crews are in a different situation to those who work outside the aviation world because of the regulatory requirement on individuals not to operate if unfit to fly.  As such, we are aware of a UK Flight Safety Committee initiative with the CAA to look at how absence management can be better codified across the aviation community to reflect best-practice.  In fact, we majored on this topic in a recent editorial in our Air Transport FEEDBACK Edition 144 Newsletter commenting that the aim should be to produce best-practice protocols that operators can adapt to their own requirements not just for flight/cabin crews but also for other safety-critical staff such as ATC, engineers and others who must not conduct their tasks and should not be induced to work when not fit to operate (be it flying, controlling, engineering etc).

  • FC5230

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    Trainer fatigue
    Trainer fatigue

    Initial Report

    For all training duties on the line it is expected that crews report early. As a Line Training Captain the day must be carefully planned, as you cannot expect support from the trainee. A safe duty requires the trainer to complete Captain, FO and Trainer roles. These duties are rostered as per any other flight duty, 1 hour prior to STD and 30min after landing. As a trainer, the real report is 1:30 before STD, and 1hr after landing which includes debrief. Additional report writing, on average, takes an hour. Each training duty therefore requires an extra 2 hours of duty. I have raised this and have been told it won’t change. There is also resistance from rostering when I do have the energy to change off-duty times. The accumulated fatigue over a year of nearly constant training approaching 900 hours is extreme. A training duty has additional stress from the workload, and to consider these to be “normal flights” is unrealistic. We have had incident reports of tail strikes, and balked landings. I don’t feel the company safety management system of fatigue and rostering is capturing and controlling trainer fatigue. Apart from an internal confidential fatigue report, the only other person contacted was a pilot manager who was not interested.

    CHIRP Comment

    Notwithstanding this report came to us in the post-COVID recovery period when training flights were regular and frequent, the fundamental issue boils down to whether trainers should be given an extra time allowance to accommodate the additional planning and briefing/debriefing training activity. Some companies do allow extra time for the training activity within their reporting/check-in time allowances and it seems to CHIRP that this represents best practice.

    More fundamentally, although to some extent the extra burden of training is all part and parcel of being a trainer, in times of increased training flows this can soon mount up and become very challenging; being constantly rostered for frequent training duties can be extremely fatiguing and does not represent best-practice even if additional time is allowed for the training activity. The problem is likely to be seasonal for many companies and so it is vitally important that they monitor the potential for trainer fatigue especially during the Spring/Summer period when increased numbers of training flights are more likely. On a personal level, if as a trainer you feel you are becoming fatigued then do submit fatigue reports to highlight this, multiple if necessary – without data and trend information, safety management systems are unlikely to address issues that may not be apparent to them as endemic rather than just a one-off situation.