Flighty safety

AVIATION CAREER

Flight Safety management

Studies UCLA, USA

Institute of Aviation Medicine, USA

Chairman Board of Inquiry

by

Theo de Jager

Essay

Flight Safety

1980 - 1984

Survival and flight safety

At the end of my pilot training in Canada, a Dutch classmate crashed because of a mistake that these days would be generally qualified as 'human factor'. Even then, already then, I felt a strong awareness of the importance of flight safety.

I remember the slogan put into us during flying training: 'Today is your reward for yesterday's flight safety', a slogan that has stayed with me. There is always a choice between unavoidable and avoidable risks, between adequate self confidence and over confidence. Keeping moments in which margins have to be challenged because of operational requirements, as short as possible. Technical developments have made the aircraft the most reliable means, compared with any other form of transport.

The majority of air accidents are now due to the unpredictable human factor.

The possibility to study Flight Safety Management, Aircraft Accident Investigation and Aviation Physiology, gave me the opportunity to specialise into this aspect of aviation, after many years of experience as operational fighter pilot, followed by cargo- and passenger pilot, instructor and examiner.

Aviation physiology

Coincidental contact with the most senior physician at the Ministry of Defence, opened already in 1967 an opportunity to apply for a post-graduate training for medical doctors at the Institute of Aviation and Aerospace Medicine in San Antonio, Texas, USA.

This institute was engaged in the space program for astronauts at NASA. It was tasked to prepare future astronauts and familiarise them with the physiological aspects of traveling to and staying in space. Furthermore, physicians were trained as flight surgeon, responsible for medivac, medical evacuation flights, and specific flight medical aspects. There was a vacancy for an already purchased training slot, but no medical doctor available. My chance!

The students consisted of twenty five medical doctors coming from the 'whole world', a NASA gradute-engineer com medical doctor under training, and myself. An interesting group of students from many different cultures. After the first lecture it became clear that it would not be easy to manage the course. My basic knowledge consisted only of the physiology lessons during my initial pilot training and some additional courses I followed during my flying career. Not enough!

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The Institute of Aerospace Medicine, San Antonio, Texas

My neighbour on the campus was a Portuguese doctor who was willing to help me with my lack of medical knowledge. Furthermore, it was possible to review the lectures on video, available at the library.

The subjects in the area of under-and overpressure effects on the human body, such as lack of oxygen, the effects of G-forces, accelerations and decelerations, to the heart, brain- and muscle functions, vision, red out, black out and grey out, sense of balance (vertigo), blood circulation and hearing, were extensively covered. In addition, scuba diving, including compression, decompression and recompression were practised and experienced in the pressure chamber of the school, as part of the program

Shortly after our arrival in San Antonio, we were received by the Governor of Texas and as a token of welcome and hospitality, honoured with the status of Honorary Citizen.

This turned out to be a useful status later on. Two German doctors in my course bought a second hand 'American' car. They invited me to join them on a trip to the Gulf of Mexico. Barely on the highway, toward the Gulf of Mexico, we stopped at a petrol station to buy some fuel for the journey.

Behind us in the cue was a pick up, rifle visible on the back seat, waiting for his turn. The pick up driver asked us where we came from and what our destination was. When he realised that we were on our way to the Gulf of Mexico, he looked at our tires and said 'On those tires?' and ordered the petrol station's owner to change the tires.

We told our benefactor to be honorary citizens of Texas and this really opened doors. Our 'cowboy' turned out to be the owner of a large ranch nearby. He also had a private plane in his hangar, a Beach Craft Bonanza, for his business as banker, and a number of helicopters for his flying cowboys, to drive his cattle.

He proudly showed us around on his ranch to view his hangar and private plane, a private concrete runway and the original house of his parents, still well maintained by a special staff. The new house he lived in, reminded us of ranches in American movies. After an extensive lunch, we could continue our trip on the new tires, gift of the generous Texan.

The midterm exams showed that a doctor from Taiwan, having difficulties with English, and I had scored marginal. Therefore, I asked my Portuguese neighbour for some extra tutoring. The result was that the Taiwanese doctor and I, as non-physician, were rewarded for our extra efforts, ending with the highest final score in the final exams of our course

After graduating, I stayed with the institute for a few months, to practice what had been learned, working as an assistant in the pressure chamber where astronauts, pilots and flight surgeons experienced the phenomena of compression, decompression and recompression.

We were also using the pressure chamber for the treatment of scuba divers, who had come up too fast after diving. They had to be recompressed and then gradually taken back to sea level pressure, according to a calculated scheme.

The colleagues around me had forgotten that I was not a real flight surgeon. Along with them, I was invited to Houston hospital to attend a so-called hyperbaric, high-pressure, operation. The pressure in the operation room was increased, expecting the bleeding would be limited. Many years later, when flight safety management was my profession, I had the advantage of the knowledge I already 'accidentally' had acquired.

Flight Safety Training and Testing Centre, VOTC

Looking back, it seems no coincidence that already in the beginning of my career in aviation, I was confronted with the importance of flight safety in a broad sense. There was a vacancy at the VOTC and they thought it to be a good idea to appoint a pilot who had saved his life twice using the ejection seat, for the job. That was I.

It was a side job, next to my operational duties as a fighter pilot. Within the test centre, it was agreed that I was to instruct the use of safety equipment and become member of the evaluation and test team, for the purchase of new equipment. This agreement worked well. I had the job for three years with the greatest pleasure.

Gradually I became an expert in the field of ejection seats in use by the Dutch Air Force, following and analysing accidents within NATO whereby the ejection seat was used.

Internationally too, there was interest in my work, published in professional magazines, resulting in invitations to give lectures on this subject in Germany, Great Britain and the USA. These lectures gave an opportunity to share experiences in other countries, to evaluate and compare.

Flight safety management and aircraft accident investigation - 1980

The opportunity to study flight safety management appealed to me. They were looking for two pilots and a graduated engineer. The pilots had to upgrade their bachelor degree, and had to pass exams in advanced mathematics and statistics, after an intensive 'private' course by Dr.Doyle, an excellent teacher. This worked out well and we were allowed to join the other students.

In 1980, there was only one university with a Masters program in Flight Safety Management and Aircraft Accident Investigation, the University of California, Los Angeles: UCLA. The National Transportation and Safety Board, the NTSB sponsored their program. They, the NTSB, are responsible for the safety of all means of transport and the investigation of serious accidents in the U.S.A. The current organization in Holland (2009), The Council for Safety, is almost a copy of this NTSB model

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UCLA campus, Los Angeles, Ca-Royce Hall

The course

The course started with a presentation of the syllabus. Before qualifying for this MA- course, I had to pass an exam in statistics and mathematics. Because most accidents are due to the human factor, also an exam in psychology was included in the curriculum. Much time was spend on interview methods, techniques and their interpretation. Also communication as a tool to promote and organise flight safety. Because of the probable medical aspects even aviation physiology was included.

Metallurgic and material science, dealing with material fatigue were major subjects. General - and flight safety management also received much attention. As a practical exam, a team of students had to organise a large event, including the flying program, public relations, press releases, leaflets, posters, et cetera.

Timing was the main key. The assignment for my team was a script for a huge air show. The flying program, accommodation and catering for participants, public transport, parking of planes and cars, general catering, information, media contact, security and safety preparations, et cetera. Capstone was the application of all knowledge gathered during the course, such as investigation technique and a full flight safety survey of a real airport in California, with a group of graduates, acting as a Board of Inquiry. We were a small group of students from different countries, all with the necessary practical experience as pilot or engineer. Our ages were on average the same as those of our lecturers. The main lecturers were Professor Mason for psychology and interviewing technique and interpretations, Dr. Doyle for aerodynamics and mathematics, a German professor for communication science. He, professor X himself showed little of this in real life. His views, when questioned, because they collided with our common sense, often caused irritation on his side. Reason for an open discussion with the students, trying to change this behaviour. The professor said to appreciate our criticism, with the other lectures we became friendly and developed a pleasant social contact outside the university.

Each of us was assigned a personal mentor. During a well-organised reception, at the beginning of the course, the voluntary mentors, staff member of the University, were introduced. These mentors also coordinated our free time activities and events, contributing this way to the great atmosphere amongst the group, including the lecturers. A visit to the Hollywood Studios, Disneyland, Palm Springs, SeaWorld in San Diego, skiing for enthusiasts, barbecues and cocktail parties at their homes.

Personally I got a special contact with Prof. Mason. For the written exam, multiple choice, in his subject psychology, I had everything right. Still, I got only 98%. Protesting against it did not help. The oral exam was a special one. The opening statement of the professor was that I believed to know him. My answer was that I of course had an impression, but no more than that. Ignoring my answer, the verbal exam question was 'Since you know me so well, what is the colour of my front door? ' Since the professor in his appearance, the way he dressed, always had something conflicting or detonating, I asked him to name a number of colours and chose the most extravagant one. It turned out I guessed correct and passed my verbal exam.

Aircraft Accident Investigation

Parallel to the theoretical lectures at UCLA, an experienced accident investigator from the NTSB gave us practical instruction. On a reconstructed crash site of many acres in San Bernadino, south of Los Angeles, wreckages of previous accidents had been spread out in the field in the same way as they were found at and recovered from the original crash site.

We practiced to take inventory at the crash location according to a proven format, mapping each part and then methodically analysing the (probable) cause of the accident. This was a very time consuming procedure, questioning and motivating each finding and trying to arrive at a common conclusion within the team.

The main rule we learned and applied was, not to jump to conclusions. A wise advice. Not only in accident investigation.

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My first Commission of Inquiry at Newcastle - UK

Interviewing witnesses and involved parties was also included in the final project. We had learned how unreliable witnesses can be, in spite of their sincere effort to reproduce their actual observations and facts. Adding to their statement, in order to make their story logical and match their opinion was common. In our lectures and role play we had already discovered how a perception of observation or facts by different persons can be totally contradictory in given statements.

An important part was dealing with the press. Compiling an initial interesting press release, without revealing anything. Also surviving the interviews by the media, including the follow-up interviews during the ongoing investigation.

The important rule was to never suggest who or what to blame or indicate options. There are so many interests and parties involved, such as the airline, air traffic control, the aircraft builders, the passengers, their lawyers, insurance companies, et cetera. They all try to escape or claim liability. There is the big legal issue at the end, often taking years of negotiation.

Analysing all the information, interpret the detailed transcripts of radio and intercom traffic, including that of the black box and cockpit voice recorders, was important. Out of the total of all the information obtained, including reconstructions, it is attempted to arrive at the actual or probable cause of the accident.

To conclude the practical phase we, the students, were to act as a Commission of Inquiry to investigate an actual accident or a staged one at the school's crash site and implement all we had learned under supervision of experienced accident investigators.

After completing the university exam, a Masters in Aviation Science, and some assignments in the USA to gain experience, I returned to Holland and was appointed "Standing Chairman of the Commission of Inquiry for Aircraft Accidents". In addition, I was to maintain my proficiency as captain. A perfect combination.

This was my last job in aviation. Three accidents were investigated by our committee. The first was a parking accident with damages at the platform of the airport of Dakar,Senegal. Well known to me from an earlier assignment.

A Dutch and a Canadian aircraft were damaged. Both were parked next to each other, but not secured for the storm coming in by surprise from the Atlantic. No witnesses could be found. A statement based on assumptions, to please the insurance companies, was the best we could do and was accepted as sufficient.

It so happened that I met a former Dutch Air Force colleague, Jan Spronk, in Dakar. He had immigrated to Canada earlier and now flew as captain for WPA, Western Pacific Airlines. The other fatal accident was with a Dutch commercial aircraft near Newcastle, UK. The last one was a collision of a helicopter in Holland, with high tension power lines. In all these accidents the cause could be determined. For personal reasons I decided to terminate my aviation career and apply for retirement. More than 25 years later, I experience the privilege of writing down some of my memories, looking back with pleasure at working in aviation during 32 years. Lagos. Portugal 2014