Bombardier’s Safety Standdown

Despite piloting a Gulfstream G650 these days, Bob Agostino still thinks of himself as a student of aviation safety as well as the art of flying. A former member of Bombardier’s internal accident investigation team, he also happens to be a particularly good source to query about the company’s first safety meeting that he helped create in 1996. The Safety Standdown, which began as a series of internal educational sessions for Learjet demonstration and test pilots at Bombardier, has grown in the past 20 years into the world’s premier aviation safety experience. A look back at the Standdown’s roots offers some interesting insights into why so many aviators place such a high value on the annual event in Wichita, Kansas. Few pilots even realize that the first conversations about high-altitude aerodynamics, stalls and stall recovery, loss of control, and upset prevention and recovery training (UPRT) began at Safety Standdown more than a decade ago.

A veteran of the National Test Pilot School at Mojave and a flight instructor, Agostino remembers back in 1996 when, as Bombardier’s director of flight operations, he found himself combing the details of many Learjet accidents and eventually other aircraft mishaps. “The nameplate on the airplane had become irrelevant. We kept having the same three or four kinds of accidents again and again, so I asked our demonstration pilots, as well as our safety officer, Dave Ryan, if they had any ideas on how to prevent them,” Agostino says. “One former military guy said that, after a number of accidents, his wing would ‘stand down’ until they better understood the problem. We all wondered, why not stand our group down before the accident rather than after?”

In the early days when the number of Standdown participants could be counted on two hands, Agostino remembered advice from the late Scott Crossfield, a legendary test pilot. “He said he didn’t believe in safety. What he did believe in was competency and that safety was a result of competency, not an entity unto itself.” Agostino realized Crossfield’s insight applied to operating any airplane, especially considering that 20 years ago, few civil pilots ventured above 41,000 feet. Today’s business jets can ­easily climb to FL 510, where many pilots’ understanding of their environment and how they got there is often as thin as the air surrounding their airplanes. “We don’t really train pilots anymore,” Agostino says. “We’re training heavy equipment operators,” a concept often heard in the halls between sessions at Safety Standdown today. But what does that mean to pilots and technicians in the industry today?

“Between 1975 and 2005, there were at least 500 additions to FAR Part 25 [used to certify transport-category aircraft]. But not much has changed when it comes to pilot training [in that same time period]. We don’t teach spins or demand upset recovery training,” Agostino says. “When you take away this kind of training, why would you be surprised that we’ve seen so many loss-of-control accidents?”

Civilian pilot training is considerably different from the U.S. military, he adds. Civilian training tends to focus on systems, minimal ­tactics and the check ride, but little else. In high-end transport aircraft, it’s not unusual for a pilot to successfully pass a type-rating check ride, never having set foot on board the real aircraft. By contrast, Agostino says: “Military pilots focus on intense academics taught by professionals who live those academics and don’t just memorize the syllabus. Military pilots are put through intensive ground and simulation training before moving to flight training.” The link to civil training today: “We created the Standdown to give back to an industry that had been good to all of us, but perhaps had not focused as much effort as it should trying to keep us all safe. We knew our pilots and mechanics were good people, they just weren’t being taught very well.”

The Early Days in Wichita

Agostino and Dave Ryan both recalled when the Standdown idea really began gaining some traction in 1996. During a customer demonstration flight, Agostino mentioned the program to a client who quickly suggested they go public. Shortly thereafter, the Bombardier team began inviting a small number of customers to attend. By year three, Ryan said the FAA was attending and supporting the idea of training beyond the minimums. By 2005, Safety Standdown was successful enough to draw 550 people from the U.S. military, the public sector, business and general aviation.

Early editions of Safety Standdown focused around topics the Bombardier demo and test pilots believed were missing from civil pilot training, like more intensive aerodynamics, high-altitude physiology and aviation psychology. Agostino and the team knew they’d need more than just engaging speakers. They’d need people who were also subject-matter experts if they were going to begin changing minds.

“We didn’t want speakers who could teach a course based on a book they’d read. We got the people who wrote those books,” Agostino says. They asked Gene Cernan, the last man to set foot on the moon, and he said yes. Human-factors expert Tony Kern was one of the first regular speakers. Ryan recalled pitching the Standdown idea to Kern. “I just cold-called him, and before I knew it, we’d talked for an hour and a half about aviation safety. And then, when I asked him to help, he just said sure.” Kern has spoken at every Standdown since, and his airmanship model is still used today as a key element of the program.

Ryan says, “One strategy for the Standdown was to tease the audience with just enough expert content to make them want to seek out some of these speakers after the conference for additional help.” While none of the speakers are paid for their work, Ryan said it didn’t affect the quality of the presentations, even from the beginning. He recalled early speakers like ­psychologist Dr. Jerome Berlin and sleep authority Dr. Mark Rosekind. The 2016 Standdown in Wichita last September featured other talented safety professionals like the National Transportation Safety Board’s Robert Sumwalt, who also walked away with the 2016 Safety Standdown Award. B.J. Ransbury from Aviation Performance Solutions has become a regular in the high-altitude aerodynamics sessions, supported by people like National Business Aviation Association President Ed Bolen, retired U.S. Navy Capt. Al Gorthy and Tom Anthony from the University of Southern California’s School of Aviation Safety & Security.

Surprisingly, the Bombardier Safety Standdown has never charged attendees a dime to be a part of the action, not even during the depths of the recession, for which attendees credit Bombardier itself. Even breakfast, lunch and often dinner are included for people admitted. Attendees pay only their transportation and hotel costs. Each year, the ­number of applicants exceeds the number of available slots. Because the real goal is to spread the gospel of aviation safety from a new perspective, the Standdown has expanded into the digital world. Major sessions and some breakout events are broadcast live on the Internet and later archived at safetystanddown.com.

Changing behavior, even simply convincing people there’s another perspective worth considering, is no small task. Standdown organizers thought for years it was only corporate accountants, the people holding the training purse strings, they’d need to work on to increase attendance. Agostino says the team was surprised to learn it was often the pilots themselves who believed intensive training in aerodynamics, human factors and loss of ­control just wasn’t that important, he says, “because the FAA didn’t require it.”

Agostino remembers too the more in-depth explanation pilots offered, ideas still floating around the industry today. “They still think the electronic eye candy in their cockpits will keep them safe and that professional pilots are paid to avoid dangerous areas of the flight envelope anyway.” But what happens when they see an event they’ve never experienced, like a 70-degree upset 1,800 feet above the ground? Agostino says just the thought of those upsets terrifies many pilots today.

The 2016 Standdown

“Flying is both an art and a science,” he concludes. “If we can fix the human part, we eliminate most accidents. But we need to start training for that now.” Raising the topic of cognitive dissonance, Agostino says, “Too many of us only read information that confirms what we already believe and never look at anything that challenges those notions.” Helping to remedy that problem is where the Standdown ­organizers say they really earn their bread and butter. Of course, everyone realizes that the pilots who really need to attend Safety Standdown seldom show up to experience this kind of altered thinking.

The topics at last year’s event ran the educational gamut, including Dr. Quay Snyder’s “Ending Substance Impairment in Aviation,” to USC’s Tom Anthony’s “The Seven Elements of Aviation Security,” Chris Lutat’s “Automation Airmanship and the 21st Century Go-Around,” Tony Kern’s “The Will Is More Important Than the Wings,” Robert Sumwalt’s “I Know You Can Fly, But Are You a Good Leader?” and B.J. Ransbury’s “Hazardous Mental Attitudes Surrounding Loss of Control.” There were 30 sessions in all, taught by people who have indeed written a book or two on their subject areas.

Always good for a bucket of cold water in the face of training complacency, Kern spoke this year about “Sorcerers, Mad Scientists and Safety.” His easygoing yet revealing style allows him to gently mix a bit of humor with his decades of military flying, history and human-factors study experience to create more than just a lecture. He’s the kind of guy who could tell you that you’re absolutely clueless about life and leave you smiling when he did. Attendees to Kern’s sessions are also reminded the moment they walk in that smart people are still out there destroying perfectly good airplanes, along with their passengers and cargo. He sees it as his mission to rattle contemporary thinking on aviation safety today — to rattle people enough that they’ll go back and spread the word in their own flight departments.

This year, Kern began with details of the hurricanelike change coming down the road. “We’re going to need to bring some 500,000 new pilots, mechanics, air traffic controllers and airport managers into the system over the next 10 years. We’ve worked ­regular science for a long time, fairly successfully.” But today, lawyers are often ­helping to create procedures to minimize litigation. Because pilots are clever folks, they see huge holes in how some of these procedures can be applied and believe they can get away with casual noncompliance, thinking today’s new high-tech cockpits are there to act like shields against any real danger. Wrong, according to Kern. He thinks automated cockpits are actually ­working against aviation safety these days because many aviators find this new environment quite unengaging at times, perhaps lending itself to more noncompliance events.

“We need to reconfigure how we train people to fly when [an aircraft] is completely automated and relatively boring,” Kern says. “It’s going to take something beyond our traditional scientific approach to safely do it. We’ve substituted data-gathering for improvement, but we need some breakthrough thinking fairly quickly.” He says he believes new technology and safety improvements removed many of the drivers for human-factors improvements over the past 15 years. “We’ve revolutionized mediocrity because we’re not breaking airplanes [the way we used to]. People still think of aviation as an example of how to manage high-risk environments, but we’ve actually stopped evolving. And we didn’t get to be this good by thinking this way.”

So where do we go from here? Kern has begun hanging his hat the past few years on personal accountability and why individuals need to become part of the solution to improve aviation safety and stop waiting for everything to come down from above. He told the younger members in the audience that how they cope with their first experience with casual noncompliance, whether it occurs on the shop floor or in the cockpit, could set the stage for their careers. He hopes they won’t just look the other way. He believes that if we don’t begin teaching people that this sort of behavior is not OK, we’re doing them and the entire industry a huge disservice.

Kern spoke to how focusing on pride, character, professionalism and discipline can alter a career and an industry. “The real scientists call this kind of human-factors talk just a soft science,” he says. “Too many of us don’t like talking about anything that’s not technical. But we need people who can talk about this stuff, about the metaphysical … the things that are not easily measured.”

He sees those soft skills as critical to climbing out of the “crushing grip of mediocrity” that so many people are locked into, a grip that makes people believe that being effective at their jobs is good enough, that meeting standards means they understand what needs to be done — a concept with which Kern disagrees. “We need to be operating in an area of continuous improvement.” But why bother when the FAA or the boss thinks meeting standards means things are OK? “Just because you’re trapped in that crushing grip of mediocrity [meeting standards] doesn’t mean nature is required to offer you a test someday that matches your skill level of simply ­meeting standards. If more is required and you’re not ready, you’re probably going to die.”

He explained it’s time to “redefine what the right stuff is when hiring people today, when 95 percent of the work is automated and can be quite boring. Maybe we need to select people differently. Maybe we don’t want people like us today at all, in fact.” As people’s jaws are still hanging down at this point, about 45 minutes into the presentation, Kern warns them of something he said years ago. “In 2010, I keynoted the NTSB forum on professionalism. I predicted the accident rate for Part 121 carriers would eventually increase by 400 percent. You have inexperienced people working next to others who have learned what rules they can avoid.” He sees that as a recipe for disaster.

Kern says he wants the aviation industry to look for the challenges each and every day, even if they’re only small ones, that focus on ­improving, striving to create that mindset of continuous improvement. Holding us back are some of the items the industry seems to believe are pushing us forward, like gathering big data. He says this is wrong-headed thinking because it makes us focus on where people have screwed up and, hence, is why everyone is so focused on keeping the data secret and de-identified.

“But what if we focused on what people are doing right, if we looked for best practices? Breakthroughs come from people who are curious. Not everything needs to be evidence-based [before we try it]. We need people who are bold enough to stand up and take the spears,” Kern says.

But individuals need to convince themselves first of the need to rise above minimum standards. Kern asked the audience to stand with him on this industrywide challenge.