Safety Standdown

Bombardier’s conference is still going strong in its third decade.

Despite an industry inhabited with thousands of gigantic egos, most aviation folk will probably admit, some secretly, that they wish they had a mentor, a guide to prevent them from falling into any of the thousands of professional pits waiting for the unsuspecting or poorly educated. Who wouldn’t like advice from someone who has been there before and knows the answers to important questions such as the best initial education, job-search tips or even how to hang on to the position they already have? Imagine too learning just how to safely move an airplane and its cargo of passengers from engine start to shutdown?

When it comes to aviation safety—whether the topic is fatigue, cockpit and cabin operations, or the late-night replacement of an APU in time for an 0600 departure—Bombardier’s three-day Safety Standdown has risen high on the must-attend list for aviation practitioners around the globe over the past 23 years.

The first Safety Standdown was the brainchild of a team of pilots led by Bob Agostino, former director of Bombardier’s flight operations in Wichita, Kansas, following a tough accident investigation. Also an experienced investigator, Agostino asked members of his department for suggestions, and one, a US Air Force veteran, mentioned how the military dealt with similar issues: “We’d stand down [from flying] until we figured out the cause of the problem.”

Agostino realized there was no reason to wait for another accident to the search for answers. Not long after, the first Safety Standdown was launched as an internal training tool for Bombardier’s seven-pilot Wichita flight department. In 1997, the Safety Standdown expanded to include Bombardier’s research-and-development teams and the company’s test pilots. A few years later, customers were invited. By the turn of the century, the doors were opened at no cost to other flight departments and individuals.

The rest is history, with more than 10,000 people having attended the SSD since the beginning, including professionals from the airlines, business aviation, the military, aircraft OEMs, a variety of government agencies and industry associations, such as the National Business Aviation Association, which co-sponsors the event.

While most SSDs have been held each fall in Wichita, the 2019 event attracted 543 people to Fort Worth, Texas. All available SSD slots were spoken for just eight days after the first announcement, leaving 143 people on the waiting list. Many of the presentations were, however, broadcast on the web and archived for operators around the US and in dozens of foreign countries.

Bombardier Safety Standdown
Tony Kern has become the conscience of Safety Standdown. Courtesy Bombardier

So what’s the Point?

You could think of the Safety Standdown as annual safety refresher training focused around a theme; this past year’s was “Learn, Apply, Share,” meant to reinforce the SSD concept that simply meeting any regulator’s minimum standards should never be good enough—for anyone. The lessons contained in SSD sessions can easily be applied to pilots and technicians in most any category because event organizers believe every aviation professional has the responsibility to learn, to seek as much information as possible from already-existing human factors and technical training. Each year, the SSD adds to that body of knowledge.

Some of the more tantalizing of the two dozen topics presented at the most recent SSD came with titles such as “When Your Cockpit Becomes Your Enemy” and “Emotional Well-Being in Aviation,” highlighting a few of the problems inherent in what some experts view as the narrowly focused aviation education being dished out today. The problems surrounding that education are expected to grow over the next decade as hundreds of thousands of new pilots and maintenance technicians begin careers around the world.

If the SSD were ever to name a dean emeritus, that title would surely fall on Dr. Tony Kern, an engaging, self-effacing, animated and humorous voice who’s constantly nudging participants to improve their personal performance beyond minimum standards. Kern is chief executive officer and a founding partner of Colorado Springs, Colorado-based Convergent Performance, a company focused on optimizing people’s personal and professional performance. His well-known fictional-character-based speaking style—where he once entered the room looking like Sherlock Holmes reincarnated, preeminent thinking process included—manages to stay just far enough away from that of motivational speaker Tony Robbins to hold the interest of professionals in aviation.

Bombardier Safety Standdown
Teaching others how to remain in command of their automation is Chris Lutat’s specialty. Courtesy Bombardier

Before creating Convergent Performance, Kern—a retired lieutenant colonel in the US Air Force—served as a command pilot and flight examiner as well as chairman of the Air Force’s Human Factors Steering Group. He was spurred into the human-performance field after two of his Air Force students lost their lives in 1992 when their B-1 bomber slammed into a ridgeline on a moonless night. Kern studied and wrote tirelessly after that as a way to come to grips with where he might have had failed those two pilots.

Kern easily slipped into the role of the Safety Standdown’s conscience as he spoke to the topics industry insiders should already know but often don’t want to hear. He’s the mentor everyone wishes they had because he knows how to help them up their game, identifying the process as a battle between who each individual is today and who they want to become. This year, he opened the SSD with a talk entitled “Levitation Is Not a Magic Trick: High Performance at the Merge.”

The merge is “where our goals, our objectives and our standards are challenged,” Kern said, “when people are not willing to live up to standards and [must deal with] complacency and cultural norms.” He asked the audience to think about people they work with who don’t live up to their potential. “They may be smart, with great stick-and-rudder skills, but they just can’t execute them in real time.” The question is, why? “It’s hard to fight an enemy with outposts in your head.” For instance, he said, “Now you’re a captain, and you plan to enjoy it, so satisfaction and complacency actually become the enemies of improvement.”

Bombardier Safety Standdown
The Safety Standdown brings together industry leaders from the FAA, NBAA and Aircraft OEMs. Courtesy Bombardier

We all say enhancing personal standards enhances safety—is that just talk? “Elevating our standards really means nothing if we don’t elevate our performance to reach those standards.” Adding a small dose of reality, Kern said: “This might be the most important Safety Standdown you’ve ever had because, here, we lay a lot of foundational bricks. If we’re really going to elevate our standards, the only thing left is to figure out how to do that. Safety Standdowners are a tribe of doers. So choose whatever standard you want and drive it into the fabric of your being. You’re only as committed as you are convinced. As you become convinced, you’ll learn it’s hard to change a habit or behavior. But habits are better than rules, though, because they keep you—you don’t need to keep them.” He expressed his belief that people leave SSD only one of two ways. “You’ll either network a little bit, make some friends, leave here feeling good, and maybe leave with a list of standards you want to improve but get caught up in the day-to-day business and not do a thing.” Or maybe, he said, you’ll take action. After saying this, he grew silent to let the point sink in.

“It’s not hard to fall below minimum performance standards. But keep in mind that your aircraft, Mother Nature or other airplanes—the entire world around you—[are] not under contract to present you with a challenge at the minimum regulatory standard. How many of you ever had to perform nearly perfectly just live? Often enough that we know it happens. Things that ‘never happened’ before, happen all the time,” he said. Headed toward his final points, Kern said: “Deliberate practice is about taking one small part of your life and refining it until you can’t possibly get any better. People who reach world-class status didn’t practice more, they simply practiced differently, sticking with it for at least 30 days to show the results. But if you try it, you’ll be asking yourself why you didn’t do it before.”

Confirming why his emphasis on performance above standards is so important, he asked the audience to support a survey question: “What percentage of you would admit to knowingly violating a standard, even a tiny one, in the past 60 days?” Plenty of hands went up, and Kern surprised everyone with an 86 percent figure. When asked what kind of standards he was talking about, Kern said they include “proximity to thunderstorms, sterile cockpits or even fuel reserves. If we all just agreed to live to minimum standards, the industry would turn around. To elevate your standards, you need to be authentic and genuinely care. You need to give back to others. Begin by following all the rules all the time, no exceptions. Care about raising the bar for others and you will raise it for yourself.”

Bombardier Safety Standdown
More than 500 people attended the 2019 Safety Standdown. Courtesy Bombardier

In Command of Our Automation

As he began his session, “Rising Above Technology: Performance Standards for 21st Century Airmanship,” Chris Lutat said, “I’m just a pilot.” A check airman and instructor for a major cargo carrier, Lutat co-authored the popular aviation book Automation Airmanship: Nine Principles for Operating Glass Cockpit Aircraft.

In the past decade, cockpit technology has, in fact, become one of the most sought-after topics for Safety Standdown audiences—probably because, deep down inside, many crewmembers realize the depth of their knowledge isn’t as deep as it should or could be. “So why elevate our standards when it comes to airmanship and specifically automation?” Lutat asked. “If we wait for the regulators to change our standards, it’s going to be a long wait. Look how long it took to vet and implement a high-angle-of-attack training program.” If distraction, patience and commitment help create our vision to getting home safely each day, Lutat said distraction is the real enemy. However, he suggested some other familiar barriers to self-improvement: “complacency, our egos, time, stress. How often do we just run out of time to update our standards?”

On to some automations issues: What do the highest-performing crews do—the people actually raising the bar? Reflecting on Kern’s earlier session, it often comes down to awareness. “There are times when we skip over one little preflight item or violate a seemingly tiny standard procedure,” he said. “Every time we forgive ourselves for not being the best, we begin eroding our chances, and…the next time, we’ll do the same thing.”

Bombardier Safety Standdown
Safety Standdown breakout sessions often deliver ­hands-on experiences. Courtesy Bombardier

He highlighted the senior UPS crew in the pre-dawn crash of an Airbus A300 at Birmingham, Alabama. The flying pilot failed to tell his copilot that, while she was off the radio, he’d switched the airplane to a vertical-descent mode in abject violation of company procedures. There was also much to learn from the Air France 447 accident. That crash focused on erroneous airspeed indications and the destabilization of the aircraft as it transitioned from a climbing flight path and pitch attitude. The crew likely never understood they were facing a simple loss of airspeed resource information that created erroneous airspeed numbers and warning messages.

When it comes to automation and how much a pilot really ought to know, Lutat believes understanding his well-known five levels of aviation automation proficiency could be a good place to begin. Level 1: The pilot demands constant correction and is clumsy and slow on small items. Level 2: Pilot actions are mostly correct and appropriate with only minor deviations, and most tasks are accomplished by rote. Level 3: A pilot’s performance is safe and efficient. They understand automation logic and require little correction, meeting minimum standards. Level 4: The pilot displays an above-average understanding of automated systems, with errors corrected before they impact the flight. Level 5: The pilot displays flawless performance with detailed technical understanding of underlying system architecture; the pilot actively seeks to improve their technical knowledge. (During his session, Lutat said maybe 5 percent of pilots flying today qualify at Level 5.)

Lutat clearly understood that no amount of lecturing would ever be 100 percent effective—that true learning evolves as questions beget more questions. He offered attendees a place to start if they’re serious about surpassing minimums. “Do you understand your airplane’s automation logic beyond pressing the buttons? Do you really understand the flight-control laws that govern your aircraft? Can you explain what will remain on the cockpit displays when various levels of automation begin to fail? Can you recite the missed-approach procedure step by step? It’s all about precision inside the routine. All the answers can be found in the available books on each aircraft. You just need to read them,” he said. The curious are invited to check out the resources at

Bombardier Safety Standdown
Étienne Côté offered attendees a look at cockpits that turned against their pilots. Courtesy Bombardier

When the Cockpit Becomes Your Enemy

Étienne Côté is a production test pilot and air-safety investigator at Bombardier Business Aircraft. He spoke about a relatively unknown acronym: ACI, or ambiguous cockpit incident. In plain English, that’s when cockpit instruments display conflicting information that confuses the pilot, making the answer to a given problem pretty tough to identify. An example might be receiving stall and overspeed warnings simultaneously. The airplane is unable to tell you what information is valid, or if aural or visual warnings are even accurate. ACI events often evolve into loss-of-control situations because pilots don’t really understand the interface. That leaves them to rely on their abilities, judgment, system knowledge and airmanship skills.

One of the most well-known examples of this was, again, Air France 447, when the aircraft began displaying airspeed inconsistencies. Fairly quickly, the crew lost control of the aircraft. In that accident, the autopilot unexpectedly disconnected, but that was normal for the conditions the system was sensing. The two pilots got distracted trying to figure out why the autopilot shut down; they did little else. Then they lost flight envelope protection, and the crew added incorrect flight-control inputs that made the situation worse. No one in the cockpit mentioned the repeated stall warnings. The aircraft was pitched up 15 degrees with the flying pilot holding the stick all the way back as the aircraft warned, “Stall, stall.” Of course, the A330’s automation stopped creating the aural stall warning when the flight computer’s logic didn’t think a pilot could ever put the airplane in such a high angle of attack. The computer was wrong—and the crew never escaped from the narrow box of thinking that took hold of them.

airplane landing at airport
“How often have I said to you that when you have eliminated the impossible, whatever remains, however improbable, must be the truth?” – Sherlock Holmes iStock/Jevgenij Kulikov

Sometimes an ACI occurs because of a simple mechanical failure or possibly the crew’s misunderstanding the aircraft’s modes of operation or logic. They’re relying on the aircraft to fly, but they begin distrusting it. Côté said: “Losing faith in the interface begins to narrow your thinking capabilities. An ACI begins very slowly. It’s insidious. It often devolves to an upset, which rapidly leads to a [loss of control in flight] within as little as 10 seconds. Recovery needs a committed shortcut, but what if you’ve never seen the situation before? It will take the pilot longer to solve the problem. Waiting just a couple of seconds before reacting takes out the spookiness. If you have a doubt, unloading the wing is the best first action.”

Côté concluded his presentation with a dramatic and frightening exercise, showing half the room three different PFDs indicating wildly fluctuating pitch and roll attitudes. One group saw high angles of attack, the other dangerously low pitch attitudes. He later explained the nose-high attitudes were on a regional jet captain’s PFD while the nose-low indications appeared simultaneously on the copilot’s side. It was a moonless night, and the crew most likely had the cockpit lights up as they briefed for an approach. Assuming the captain’s information was correct, the flying pilot shoved the nose down, and the crew lost complete control within 13 seconds. The ensuing crash killed the two pilots aboard.

“It’s difficult for any manufacturer to design systems against insidious failures, things you can’t anticipate,” Côté said. “Pilot understanding of energy management these days is simply declining. Failure-management principles not included in formal training are left to the operator to figure out. There’s very little available time to train for complex and slowly evolving scenarios.” When in doubt, memorize the level flight pitch and power settings for your aircraft before you need them, he said—a reasonable point to begin with for SSD attendees seeking immediate items to put into action.

Bombardier’s Safety Standdown returns to Wichita, Kansas, in 2020.

This story appeared in the March 2020 issue of Flying Magazine


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