We’re pleased and proud to be bringing you our quarterly Premium on Safety newsletter again after a yearlong break. We’ve returned the publication to its legacy look and layout. Some familiar contributors are returning and new ones will lend their perspectives. As always, the goal is to foster a lively aviation safety discourse, share and promote best practices, provide updates, and reinforce safety as a vital process that needs consistent attention. We hope you enjoy this issue and value your feedback.
In Defense of Humility
PAUL RATTÉ, USAIG Safety Programs
The ‘Ground Damage Half Dozen’ Have
you addressed
these threats?
F rom international disputes, to politics, to morning commutes, interactions rooted in hubris and bluster seem to be outpacing reasoned diplomacy and compromise. I’ve been thinking a lot lately about how unhealthy that is for let’s face it, humanity in general, but for purposes of this column aviation safety.
Inclining toward self-centeredness and away from respectful debate and collaboration as normal practice risks stifling trust and two-way dialogue. If a prevalent characteristic of today’s
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RANCE MILLER, USAIG VP Claims
Aviation demands excellence and offers no shortcuts. Countless incidents and accidents show that inattentiveness or straying from established procedures can wind up costing time, money, and even lives. Some of these outcomes can be irreversible. An ounce of prevention is a much wiser investment than the pounds of cure possibly needed later.
Ground damage isn’t the far-fetched or low-frequency threat we might wish it is.
Advanced training and safety programs thankfully prevent most aviation workers from ever getting firsthand experience with a catastrophic aviation accident. But it’s telling that 52% of respondents to a recent NBAA safety survey had experienced at least one aircraft ground incident or close call in their own organization within the past 2 years. Ground damage isn’t the far-fetched or low-frequency threat we might wish it is. Is your organization adequately prepared to manage what happens to and around your aircraft on the ground?
Aviation puts a spotlight on everyone involved. That’s welcome when we’re living up to the standards of excellence expected, but not so much when that standard has slipped. It’s one level of challenge to manage risks when parking, servicing, hangaring, and towing aircraft at home. Defending against ground damage in less -familiar environments and working with people and equipment not of your own organization adds to the challenge. Simply put; distractions, procedural breakdowns, or
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social discourse cuts against those pillars of safe fl ying cultures, it’s worth taking steps to make sure things stay different (and safe) in your aviation circles.
Some years ago, I was Chief Pilot in a government fl ying outfit with about 60 pilots. A crew landed an aircraft safely after an inflight malfunction, but there were some concerns with the underlying decisions made. I scheduled some time with the PIC after things settled down for what I hoped would be a constructive (and possibly teachable) chat. I barely got a chance. The instant I expressed anything other than ‘congratulations’ the defenses came up. After expressing disbelief that I’d ‘come after him,’ the pilot, hands on hips, said, “because I’m the best pilot you’ve got.” I don’t recall this exchange all these years later because the ensuing talk went so well (it didn’t). I remember it because of the thought that struck me right then and has stayed with me since: no way does ‘the best pilot’ in any group say that.
Acquiring knowledge, experience, and purposefully maintaining proficiency leads to competence. Among the best pilots, technicians and coworkers I’ve met, a common trait is that after they reach elite competence, they wield it quietly. That makes them approachable and continual learners from successes, mistakes and experiences their own as well as others’.
If you aspire to earn a reputation as the ‘best’ at anything, practicing quiet competence rooted in humility will level you up. On the other hand, few things can move you more decisively away from that distinction than being certain you have all the answers, paired with a wrecking -ball approach to proving it.
Stay well, fl y smart and fl y safe. ( Humble too.)
corner-cutting during ground operations, at home or away, expose your operation to the risk of unexpected and unwelcome damages. Avoiding physical damage to aircraft is a prominent focus in managing ground risks. But don’t discount impacts to your personnel, equipment, company reputation, time, operational capacity, and finances. Here are six of the most common ground occurrences encountered by aviation insurance professionals the Ground Damage Half Dozen:
1. An unassisted flight crew taxiing into a stationary object.
2. A flight crew impacting a stationary object while being marshaled.
3. Inadvertent towing damage to an aircraft by a ground crew.
4. Ground contamination of a ramp or runway causing ingestion or jet blast damage.
5. An unsecured aircraft or item moving while left unattended.
6. A vehicle colliding with a parked aircraft.
A first step in defending against ground damage risks is to borrow the motto of several prominent organizations and be prepared. Experienced aviation professionals have seen, heard about, and lived situations that drove them to adjust behaviors to prevent unwanted outcomes from happening a second time. Small steps like carrying a back-up pen, or spare batteries for ground equipment, or planning an alternate destination airport even when not specifically required, are responsive habits born from experience. Analyze and build corresponding habits to situations your own organization has experienced during ground operations. Then, make sure the six occurrences listed above are addressed in that process. While a flight crew is taxiing, take the time to visually and intentionally assess the area along the taxi route and parking area. Note obstacles and verbally identify the location of any hazards to all crew members. The hazards might be tight turns or slopes on taxiways, other aircraft, fences, vehicles, trees, signs, debris, structures, or wildlife. Be patient. Give yourself space and be intentional and conservative while maneuvering on the ground. Consider the direction and effects of your jet or prop blast as you maneuver. Your thrust can cause damage.
Once ground support is accepted by a flight crew, the linemen and marshalers become part of the aircraft crew. Rely on them to be your eyes outside of the flight deck and incorporate their inputs, but also recognize that ultimate responsibility for the aircraft remains with the pilot in command (PIC), whom the FAA clearly defines as “directly responsible for and the final authority over the operation of an aircraft.” The ground crew can see things the flight crew cannot, but the PIC must never mentally turn over responsibility for obstruction clearance to a ground crew. Stop and shut down where you are if ever uncertain of obstruction clearance. The delay in having an aircraft towed pales compared to months of repair time, hundreds of thousands of dollars in damages, and harm to your reputation with passengers from witnessing a wing or tail strike. Always give yourself a few extra feet of clearance.
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Ground handlers have a major stake in preventing damage. Because they rely on visual cues and non-verbal communication to maneuver aircraft, they should always move slowly, deliberately, and be prepared to stop at any time. Most incidents occur when someone loses focus of their task or is unable to communicate fast enough to stop the operation. A lineman moving aircraft alone or with fewer than the prescribed number of wing -walkers to monitor wingtip and tail clearances is a recurring thread in towing mishaps. Another contributing factor is tow crews failing to take a few minutes before a movement to mutually identify and discuss obstruction hazards and confirm everyone knows the planned path of the aircraft. Finally, ground handlers’ lacking familiarity with the aircraft type or use of towing equipment that’s incompatible or in disrepair are frequent accident factors as well. If there is any uncertainty or perceived miscommunication occurring, do not hesitate to stop the operation. Some operators require flight crews to be physically present during movement of their aircraft whenever possible to observe and respond to any questions that arise. Of course, that means crews must arrive on time for planned movements. Another practice is requiring that the flight crew or a company representative be advised about, and authorize, any unscheduled aircraft movement before it’s done without the flight crew present.
should actively remove debris as it’s discovered throughout their day. This is something that’s owned by everyone; to keep a clean path as we walk through our day and ensure others are not harmed by our actions or any hazards we spot and can remove or report.
Most incidents occur when someone loses focus of their task or is unable to communicate fast enough to stop the operation.
If you see something without chocks, say something. The science behind aviation is amazing. From Bernoulli to Edison, the principles studied and developed by legions of scientists have contributed to the ability for humans to fl y safely. Laws developed by Mr. Newton affect us even when we’re not fl ying. We’ve all heard about fuel trucks rolling away, storms rearranging aircraft on parking ramps, aircraft chocks sliding on a wet or icy surface, or a cargo container going for a joyride. Every object on a ramp should be secured so it can’t become a projectile if acted on by wind or another unexpected force. Ground crews usually have chocks available for all equipment that can roll. Flight crews should carry a set suitable for their aircraft in case none are available. If you see something without chocks, say something. You might be saving yourself unexpected damage.
Airports create some natural risks. Their open expanses allow aviation to occur in a safe environment, but that can also facilitate wind blowing dust or other foreign object debris that’s collected along airport fence lines or from nearby work sites into aircraft movement areas. An aircraft or vehicle can lose a part on a taxiway. Certain treatments for ice and snow can introduce particulate debris. These conditions can result in damaged tires, ingestion damage to engines, or jet blast damage. Some of these conditions might be beyond prevention, but they can all be monitored and mitigated. Airports should routinely monitor runway, taxiways, and ramp areas for debris. PICs must stay vigilant for foreign debris threats, report hazards seen, start engines only in locations where ingestion or jet blast risks are minimal, and remain aware of the taxi route and power needed to maneuver. Ground crews
Vehicle operators unfamiliar with airport environments, who may not recognize the illusions that can be created by a thin wing, canted winglet or sloped nosecone, wind up driving near parked aircraft all too often. Straying from the intended path of their escort poses a great danger to the operators. Often, an aircraft’s wing aligns with the driver’s eye height in ground vehicles. This has lead to many unfortunate meetings of wings with vehicles and windshields. Marking wingtips, nose, and tail with high-visibility cones or perimeter rope is a recommended practice.
SIMPLE PROTECTIONS
Flight crews hand off parked aircraft to ground handlers many times per day around the globe in every weather condition, trusting the aircraft will remain in the same condition during its time in their custody. While it’s understandable for a crew to be anxious to enter a well-earned rest period, it’s also important to ensure reasonable care is taken to limit risk of damage to the aircraft before a crew departs. Be sure your ground service provider knows the status of aircraft brakes, how to contact the aircraft’s crew and company, and any specific instructions. Before the crew departs, do a quick visual survey, considering the forecast weather during the stay, for any hazards such as
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equipment that could potentially roll or blow into the aircraft. Request that the service provider resolve any concerns. It’s advisable to photodocument any issues of concern before the crew departs the ramp.
ACCESS YOUR SUPERPOWER
Being prepared for the unexpected, and mindful of ways to mitigate harmful situations before they occur is like a superpower of intuition. A threat is visualized in advance based on experience, knowledge, and training. Awareness of that threat allows a small intervention to prevent it from causing harm. That happening once is power. It becoming a habit turns it into a superpower.
Preparation to avoid ground damage begins with you, whatever your role in aviation. Once you are prepared, you can share that knowledge and behavior with your team or flight crew, then department, then company and finally the industry. This could include safety briefings to discuss close calls, learning from other operations, talking with insurance carriers about what they experience, attending open forums to discuss unfortunate situations, discovering and developing technology to aid in communication and situational awareness. The basic behaviors of communication, patience and caution can prevent any of the six situations discussed from ever occurring in your career. Safety, security, and successful flight operations rely on all participants performing to the standard of
Safety Program Resources
Finding the right resources to support a robust safety program can be daunting. To help, we’ll offer this recurring feature to illuminate various available resources. In this issue, we check in with the International Business Aviation Council (IBAC).
The International Business Aviation Council (IBAC)
Globaly Recognized Programs Promote Safety
MARJ ROSE, IBAC Communications Director
As a non-profit international trade association IBAC proudly represents business aviation interests through its observer status at the International Civil Aviation Organization (ICAO), worldwide advocacy, and the globally recognized voluntary International Standards for Business Aircraft Operators and Business Aircraft Handling IS-BAO™ and IS-BAH™ respectively.
In the world of business aviation, where safety is paramount, 'Premium on Safety' isn't just a phrase – it's a commitment. That same commitment is embodied by
IS-BAO and IS-BAH. These programs are designed to promote a proactive risk management framework that enhances a company's culture of continuous improvement and incorporates safety as a core value. The safety standards they contain help operators and ground handlers apply industry best practices by challenging them to review and compare their safetyrelated policies, processes and procedures, and then make improvements. Conformity to IS-BAO and ISBAH not only raises the confidence level of the company’s personnel, but also its customers, and insurance carriers. Being a registered organization demonstrates a commitment to operational excellence.
At the center of implementing and sustaining IS-BAO or IS-BAH registrations are its training courses and educational workshops.
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Alignment between vehicle drivers’ eye height and wingtips has led to accidents, especially at night. Marking wingtips with cones is a defense.
Workshops:
IS-BAO
Initial and Recurrent Courses
These live, online courses provide convenient and comprehensive training for operators and auditors to understand and implement IS-BAO standards, including SMS principles and audit preparation.
The Initial course is designed for operator representatives beginning the IS-BAO registration process, IS-BAO Auditors or Program Support Affiliates (PSA) pursuing initial accreditation, and new safety officers or those without prior IS-BAO experience. The 12-hour course includes one-year access to the self-paced IS-BAO Protocol Standardization (IPS) course, which is a user-friendly collection of online tutorials designed to help operators and auditors review each protocol item, highlight the intent of the standards, and provide examples for implementation. The Recurrent course helps operator representatives, safety managers, and auditors stay current on industry safety protocols and operational procedures. It’s also required for renewing PSA organizations and auditors. The 6-hour course covers updates on the IS-BAO, ICAO standards, the Audit Program Manual (APM), and on current aviation safety issues.
Workshops: IS-BAH
Fundamentals and Auditing Courses
The IS-BAH Fundamentals workshop equips ground handlers with essential knowledge about the standard, enhancing operational safety and ensuring regulatory compliance. Attendance is required for the implementation of the IS-BAH Standards. This 8-hour live, virtual course provides a practical approach to an effective SMS based on ICAO Annex 19 as a core element of day- to-day operations. The Auditing workshop prepares attendees to conduct IS-BAH audits, ensures conformance with industry best practices for business aviation ground operations, and is a requirement for auditor or PSA accreditation. The course is offered several times each year, often paired with the Fundamentals course in the same week.
SafetyNet Webinars - Free to the Business Aviation Community
IBAC’s SafetyNet Webinars include sessions covering key IS-BAO and ISBAH topics, industry best practices, and updates on safety management systems (SMS). Access to view previous webinars is provided.
IBAC & FlightSafety International Co-developed SMS Training
IBAC partnered with FlightSafety International (FSI) to design specialized SMS For Aviation Professionals and SMS For Managers eLearning courses to meet training requirements specified in ICAO and IS-BAO standards. Visit FSI’s online training portal to purchase access.
Business Aviation Security and Remotely Piloted Aircraft Systems (RPAS) Auditing Courses
A new Business Aviation Security Course focuses on security risk management, threat assessment, and mitigation strategies tailored for business aviation operations. Presented by Dyami Security Intelligence and IS-BAO/IS-BAH, this new live, virtual, two-day course imparts essential insights to safeguard Business Aviation operations. The selfpaced, online RPAS Auditor course, developed in concert with the Unmanned Safety Institute (USI), covers RPAS auditing requirements to ensure compliance with IS-BAO standards
IBAC and its safety programs are internationally aimed a reminder that the business aviation industry is innately international. The aircraft fl y anywhere in the world, flight crews travel globally, and FBOs as well as maintenance teams provide services to clients from everywhere. Operating at a level of standards and recommended practices such as IS-BAO and IS-BAH is a choice that many aspire to as an outward indicator of their focus on safety. ❖
USAIG is proud IBAC is among the participating safety services providers in our safety programs. For eligible policyholders that apply an annual Performance Vector Safety Benefit toward our ‘Preparation for IS-BAO or IS-BAH’ offer, USAIG subsidizes all or part of the cost associated with initial purchase of the standard and tuition for a workshop attendee—the first two steps toward registration. Our Performance Vector Plus good experience return program enables eligible, non-commercial business aviation policyholders holding current IS-BAO/IS-BAH registration to earn a 5% premium return for each loss-free policy year.
Back to Basics
ROBERT SUMWALT
Executive Director, Boeing Center for Aviation and Aerospace Safety at Embry-Riddle Aeronautical University
Afew weeks ago, an air carrier attempted to take off on a taxiway at Orlando International Airport. A few weeks before that, a business jet crossed an active runway at Chicago’s Midway without clearance. The problem was that a Boeing 737 was about to land on that same runway. Fortunately, the 737 crew performed a rejected landing just seconds from touching down.
According to the FAA’s runway incursion database, in 2024 there were 1758 runway incursions. Of those, 1081 (61 percent) are classified as pilot deviations. The numbers were similar for 2023.
It’s easy to point fingers at air traffic controller staffing and lack of adequate ATC technology, but the fact is, the majority of runway incursions can be traced back to flight crews.
Perhaps it’s time to get back to basics. I joined the NTSB as vice chairman in August 2006. I had been on the job for seven days when I was called to an air carrier accident in Lexington, KY. The pilots of a regional jet taxied to the wrong runway and attempted to take off. Unfortunately, the runway was not long enough. The aircraft overran the runway, crashed into a tree, and burst into flames. Of the 50 souls on board, only one survived.
The accident happened in the pre-dawn hours and weather was not a factor. The NTSB concluded that, despite airport construction and signage that did not match the Jeppesen chart that was available to the crew, “adequate cues existed on the airport surface and available resources were present in the cockpit to allow the flight crew to successfully navigate” to the assigned runway.
with standard operating procedures, including the captain’s abbreviated taxi briefing and both pilots’ non-pertinent conversation, most likely created an atmosphere in the cockpit that enabled the crew’s errors,” stated NTSB.
NTSB also noted another failure of basic airmanship: the crewmembers didn’t cross -check their position on the runway by using the most basic instrument in the aircraft – the compass. This heading information, which was clearly presented on both flight crewmembers’ instruments, would have provided the pilots with a realtime indication of their orientation relative to their assigned runway. In this case, as they aligned with the runway, the heading bug would have been off by 40 degrees from the runway heading of the correct runway.
The investigation revealed that the captain did not do a complete taxi briefing, as required by company SOP. NTSB determined that had a complete taxi briefing been done, the crew would have had greater awareness that the shorter runway intersected their intended taxi route to the correct runway. While taxiing to the runway, the crew engaged in non-pertinent conversation in violation of company SOPs and regulations, which deflected the crew’s attention from safely navigating to the proper runway. “The flight crew’s noncompliance
dogged by pilot caused runway incursions. For example, in October 2023, a Hawker 850XP collided with a Citation Mustang at a runway intersection at Houston Hobby. The pilots of the Hawker were cleared to line up and wait but told investigators they believed they were cleared for takeoff. As they accelerated down the runway, they struck the Mustang that was landing on an intersecting runway.
The Hawker pilots told NTSB investigators that as they approached their assigned runway, they noticed that the V- speeds were no longer displayed on their flight displays. One might wonder if this distraction may have led to the crew erroneously believing they had received clearance to take off. During their post-accident
A live streaming view of Midway’s active runway captured the 2/25/2025 close call as a B737 crew went around to avoid a business jet that entered the landing runway.
interview, they noted that during the takeoff roll, they were trying to resolve a rudder bias alert and a pitch trim alert.
Earlier that year an airliner landing in Boston narrowly missed a chartered Learjet by about 30 feet vertically when the pilots of the Learjet departed without clearance. The captain, who had over 22,500 flight hours, told investigators they “had heard a clearance that seems to be Line Up and Wait." However, he said he “probably responded to the clearance, but in [his] mind, they were cleared for takeoff.”
And the month preceding the Boston event, a Boeing 777 bound for London’s Heathrow crossed Runway 4L at John F. Kennedy International Airport without ATC authorization. As the 777 entered the runway, a Boeing 737, having received ATC clearance for takeoff, was accelerating through 80 knots on Runway 4L. The two aircraft were approximately 2700 ft. apart at this point. The 737 crew initiated a rejected takeoff at around 100 knots and stopped the aircraft approximately 500 ft. from where the triple seven had crossed.
The original plan was for the 777 to depart on Runway 31L, which is the most typical departure runway at JFK for heavy jets. The crew had briefed the taxi route to Runway 31L and had loaded 31L into the FMS. However, around 15 minutes before push back, the crew received their instrument clearance that indicated they would be departing from Runway 4L – the runway they ultimately crossed without clearance. The crew reprogrammed the FMS to reflect the new runway assignment and briefed the new planned taxi route.
In explaining how the captain may have reverted to his original plan of taxiing to Runway 31L, NTSB basically indicated it was habit capture –the captain was accustomed to taxiing to 31L and essentially “forgot” that the taxi instructions were to taxi to 4L. The NTSB cited another confounding factor: the crew didn’t receive the load closeout (weight and balance information) until later than usual during their taxi out. NTSB cited interruptions and multitasking related to the delayed receipt of the load closeout as contributing distractions.
We all make mistakes, so it’s understandable that the captain could commit this error. However, there were two other pilots on the flightdeck that evening – the first officer and the relief first officer. Where was the redundancy and crosscheck from those pilots? NTSB determined both of those pilots were heads down and distracted due to “concurrent operational tasks” associated with receiving the late load closeout and loading the weights into the FMS.
As a former airline pilot, I know that critical flight deck redundancy can be lost when pilots attempt to do the right things at the wrong time. There are activities that need to be done before takeoff, such as loading the FMS and doing a checklist. However, when the other pilot is performing these tasks or off ATC frequency, they aren’t monitoring the taxi progress. In 2013, the Flight Safety Foundation published A Practical Guide for Improving Flight Path Monitoring. The document defined
Number of 2024 U.S. Runway
Incursions by Category
2
Category A:
Serious incidents in which a collision was narrowly avoided.
5 Category B:
Incidents in which separation decreases and there is a significant potential for collision, which may result in a time critical corrective/evasive response to avoid a collision.
647 Category C:
Incidents characterized by ample time and/or distance to avoid a collision.
1010
Category D:
Incidents that meet the definition of runway incursion such as incorrect presence of a single vehicle/person/aircraft on the protected area of a surface designated for the landing and take-off of aircraft but with no immediate safety consequences.
Source: FAA Runway Incursion Database
Areas of Vulnerability (AOV) as those areas of operation where there is an “increased likelihood of a flight path (or taxi) deviation or the increased severity of potential consequences if such a deviation occurs.” Because approaching an active runway is considered a high AOV, a good prioritization of tasks may be for pilots to suspend doing everything other than making sure the aircraft stops short of the runway, or, if about to cross, both pilots agree and confirm clearance to cross.
FAA Advisory Circular AC 120-74B, Parts 91, 121, 125, and 135 Flightcrew Procedures During Taxi Operations specifies an important best practice: “Brief the expected taxi route to include any hold short lines and runways to cross, hot spots, and any other potential conflicts. Once taxi instructions are received, the pre- taxi route should be reviewed and monitored. It is essential that any changes to the taxi route be understood by all crewmembers.” However, there is a potential downside that such a briefing could set an expectation bias for the anticipated taxi route. AC 120-74B lays out this potential problem: “CAUTION: A potential pitfall of pre- taxi and pre-landing planning is setting expectations and then receiving different instructions from ATC. Flightcrews need to follow the clearance or instructions that are actually received, and not the ones they expected to receive.”
This FAA video provides a valuable review in under 8 minutes
NTSB’s report of the JFK runway incursion offered a sensible suggestion: “a procedural crosscheck that requires a flight crew to verbalize the number of a runway they are about to cross, as indicated by runway signs, would reduce the likelihood of future runway incursions resulting from flight crew surface navigation errors.” Indeed, if the captain would have announced that he was about to cross Runway 4L, it might have rung a bell in the heads of the other crew members to say, “Hey wait, we’re not cleared to cross that runway.”
It’s time to get back to basics. Here are a few basics to consider and practice:
• Brief the anticipated taxi route, including any hold short lines and runways to cross, hot spots, and any other potential conflicts.
• Both pilots should actively listen to the taxi clearance.
• Write down the taxi clearance.
• Read back clearances, including call sign and runway numbers.
• Have the airport diagram/electronic display out and available during taxi and cross check your position during taxi.
• All crewmembers should suspend non-monitoring duties such as loading FMS when approaching a runway.
• Verbalize your intent. e.g., “I’m going to turn left on Kilo and hold short of Runway 31L,” or “I’m about to enter Runway 4L.”
• Do not engage in non-pertinent activities while taxiing.
• Use all available resources – pavement marking, signage, nav display, to confirm selection of correct taxiway and runway.
• Were we actually cleared for takeoff? Make sure. In two of the above-mentioned examples, crews thought they were cleared for takeoff, but they weren’t. It’s a ‘no guessing’ matter. If there’s any doubt, there is doubt.
These are just a few basics. For a more complete list, check out AC-120-74B. Keep your eyes, ears, and head on the swivel. ❖
Robert Sumwalt is the executive director of Embry-Riddle’s Boeing Center for Aviation and Aerospace Safety (BCAAS). Previously, he was appointed by three US presidents to serve on the NTSB, where he served for 15 years including four years as chairman. Before that, he was an airline captain for a major US-based international airline for 24 years and also managed a Fortune 500 company’s aviation department. We’re delighted that he’s offered BCAAS as a recurring contributor to Premium on Safety
Advanced Aircrew Academy’s Aviation Challenge
Airborne Collision Avoidance System (ACAS) is synonymous with Traffic Alert and Collision Avoidance System (TCAS). They both define an airborne collision avoidance system that operates independently from ground-based air traffic control (ATC).
TCAS was designed to increase cockpit awareness of proximate aircraft through a traffic display and to serve as a "last line of defense" for the prevention of midair collisions. The system functions by tracking cooperative aircraft via transponder replies, analyzing each aircraft's projected flight path, and providing alerts if any flight paths are expected to violate specific altitude and range thresholds.
Let’s see what your brain knows about TCAS! (answers on page 15)
1. All Traffic Advisory messages (TAs) are inhibited below ____________ft AGL while descending and below 600 ft AGL while climbing.
2. All Traffic Resolution Advisories (RAs) are inhibited below __________ft AGL while climbing and below 900 ft AGL while descending.
3. Pilots should be aware of potential inaccuracies in the TCAS traffic display, especially during turns:
a. True, because TCAS does not display traffic while in turns, which could lead to confusion in a headsdown scenario.
b. True, because the displayed bearing is not accurate enough to support horizontal maneuvers based solely on the traffic display.
c. False, because pilots should be looking outside, using "see and avoid" during horizontal maneuvers.
4. When your aircraft’s TCAS is operated in the “NORMAL” mode, what altitudes are typically displayed?
a. 4900 feet below your altitude to 4900 feet above your altitude
b. 4900 feet below your altitude to 2700 feet above your altitude
c. 2700 feet above your altitude to 2700 feet below your altitude
5. Operation of your aircraft’s TCAS equipment is only required in what type of airspace?
a. If TCAS is installed, it shall be on and operating
b. RVSM airspace
Advanced Aircrew Academy—a USAIG Performance Vector participating service
c. Class A Airspace
d. Controlled Airspace
provider—offers comprehensive eLearning modules and curricula for business aviation professionals focused on enhancing crew performance and safety. We provide customized online courses, training materials, and scenario-based training to improve skills in areas such as crew resource management, emergency procedures, and operational effectiveness. We have eLearning for every person in your flight department to help meet regulatory requirements and improve overall competency and safety in the business aviation industry.
Humans in the Loop
Beyond Checklists: How Career Fulfillment Strengthens Aviation Safety
THE OVERLOOKED SAFETY FACTOR: JOB SATISFACTION
Safety in aviation is often framed in terms of technology, procedures, and regulations, but one critical factor is frequently overlooked: the people behind every flight operation. No matter how precise our checklists or thorough our training, nothing replaces the power of a motivated, confident, and mentally engaged team.
I have spent my career working alongside business aviation professionals, and if there is one thing I have learned, it is that professional satisfaction is not just about personal well-being. I believe it is directly tied to safety. When dedicated team members feel engaged, valued, and secure, they bring greater focus, accountability, and situational awareness to their roles. On the other hand, burnout, job insecurity, and poor leadership can lead to stress, fatigue, and distraction, all of which risk compromising safety.
Our industry operates 24 hours a day, 365 days a year. Many of us spend more time with our colleagues than with our families. In some cases, these environments foster camaraderie, mutual support, and trust. In others, they create toxic work cultures that erode morale and negatively impact safety. This reality makes it even more important to cultivate workplaces that promote wellbeing, open communication, a just culture, and professional development to ensure both personal fulfillment and operational excellence.
Recently, I conducted a LinkedIn poll asking my network whether they believe that job satisfaction affects aviation safety. The response was unambiguous.
As a career coach, I see this play out constantly. When professionals feel supported, respected, and engaged, they do their best work and they stay in their jobs longer, leading to less turnover and higher retention. However, when they are overworked, undervalued, or uncertain about their future, it can become more difficult to uphold the highest safety standards, and the operation gets a well-earned reputation for being a revolving door.
DEDICATED VS. DISENGAGED EMPLOYEES IN AVIATION
Studies on human factors in aviation safety confirm what many of us already know. Stress, fatigue, and dissatisfaction contribute to errors, miscommunication, and even accidents.
A 2019 study in the International Journal of Aerospace Psychology found that fatigue-related errors increased by 40 percent among pilots dealing with job stress and poor work-life balance.
THE LINK BETWEEN JOB SATISFACTION AND A SAFETY MINDSET
JENNY SHOWALTER
Additionally, a 2024 report by the Federal Aviation Administration (FAA), The Development and Implementation of a Safety Culture Survey for HighPerforming Aviation Organizations, analyzed safety culture perceptions across the industry. The findings revealed that organizations fostering open communication and strong employee engagement experienced greater adherence to SOPs and fewer incidents.
Dedicated team members are more likely to proactively identify and address safety risks before they become genuine problems. Disengaged employees may be more likely to rush through pre-flight checks, skip safety steps, or hesitate to report issues. Burnout and fatigue can impair reaction time, decision-making, and situational awareness. All of these are essential for safe operations.
THE IMPORTANCE OF STRONG LEADERSHIP
Perception and reality in leadership do not always align. Leaders may believe they are accessible and supportive, but their teams may think of them as distant or unapproachable. A leader who promotes an open-door policy but is rarely available creates frustration and detachment within the team. True leadership requires self-awareness, a willingness to receive feedback, and the humility to make meaningful adjustments when needed.
Strong leadership extends beyond managing a team or overseeing operations. It involves setting the tone, fostering a culture of accountability and trust, and leading by example. In business aviation, professionals are held to a high standard, and leadership is crucial in reinforcing professionalism and creating an environment where teams feel valued, empowered, and supported.
This includes fostering a space where employees feel comfortable discussing challenges that affect their focus, whether it is a personal or professional issue. A culture of trust allows professionals to communicate openly, preventing distractions from festering into serious risks.
Aviation is a high- stakes industry, and leadership plays a critical role in shaping the workplace environment. Toxic cultures can breed hesitation, while strong, supportive cultures empower professionals to uphold the highest safety standards.
EMOTIONAL INTELLIGENCE IN HIGH-STAKES ENVIRONMENTS
We know that pilots, flight attendants, dispatchers, schedulers, maintenance crews, FBO personnel, and everyone in the chain of command all play critical roles in safety. But technical expertise alone is not enough. Emotional intelligence, understanding ourselves and empathizing with others, plays a significant part in building a proactive safety culture.
A Flight Safety Foundation study found that nearly 70% of aviation professionals hesitate to report safety concerns due to fear of repercussions. Is that the kind of environment we want to foster in our industry? When employees feel safe to voice concerns without fear, the entire operation benefits, and safety standards improve for everyone
THE IMSAFE SELF-ASSESSMENT: A DAILY SAFETY HABIT
Addressing both personal and professional challenges is crucial for maintaining a strong safety mindset, and selfawareness is one of the most effective tools in achieving this. The IMSAFE checklist provides a structured way for aviation professionals to check in with themselves before every shift.
Illness – Am I feeling physically well enough to do my job safely?
Medication – Am I taking anything that could impair my judgment?
Stress – Am I dealing with issues that distract me from my responsibilities?
Alcohol – Have I followed the guidelines before reporting for duty?
Fatigue – Am I well-rested and ready to maintain situational awareness?
Emotion – Am I in a mental space that allows me to handle high-pressure decisions?
Honest self-assessment is a small but powerful step in preventing human error and maintaining high safety standards.
CAREER DEVELOPMENT AS A SAFETY TOOL
Few things keep professionals more engaged than having a clear path for growth. Career development is more than just professional ambition. It is a key factor in maintaining a strong safety culture.
Training and certifications ensure professionals stay up- to-date on regulations, technology, and best practices, all of which improve performance. Mentorship and networking provide a broader perspective on industry trends and help individuals build a strong support system. Organizations that invest in employee growth typically see fewer incidents because engaged professionals are less likely to become complacent or take shortcuts. When organizations commit to professional development, they typically report higher engagement and lower turnover. The result is stronger morale, better communication, and ultimately a safer and more stable operation.
A PERSONAL STORY: THE RIGHT SEAT ON THE RIGHT DAY
A few years ago, my husband, who flies in a two-pilot flight department, accompanied his dad to a doctor’s appointment just prior to a scheduled flight. At that appointment, they received devastating news. His father had terminal cancer.
My husband was understandably shaken, but there was no one else available to fl y in his place. So, he took his dad home, packed his bag, and got ready to fl y.
Because I understand the aviation industry and the added pressures of small flight departments, I asked him, “Are you scheduled to fl y left seat or right seat?” He answered that he was supposed to fl y left seat. I then suggested he share what had happened with the other pilot and ask to swap seats.
While he had to take the trip, this small adjustment ensured that the pilot with the clearer head was PIC. That moment highlighted the importance of human factors and empathy in aviation. Not everyone has someone in their life or flight department who knows to ask the right questions or propose a safer way to operate under challenging circumstances. This is why it is incumbent upon us to check on ourselves and our co-workers.
A NEW PERSPECTIVE ON AVIATION SAFETY
Jenny Showalter is a third-generation business aviation professional and founder of Showalter Business Aviation Career Coaching (SBACC). With nearly 30 years of experience, she helps industry professionals strategically elevate their careers through individualized coaching, resume writing, interview preparation, LinkedIn optimization, and outplacement services. Jenny’s aviation expertise and passion come from extensive volunteerism, recruiting experience, and involvement in her family’s former FBO, Showalter Flying Service (KORL). For inquiries, email jshowalter@showalter.com or visit www.showalter.com
In business aviation, we often focus on checklists, procedures, and training. But at the heart of safety is the individual professional their mindset, well-being, and sense of fulfillment. Professional satisfaction is not just about personal well-being; it is a key component of a safe and effective operation.
A supportive, encouraging work environment and strong leadership lead to better decision-making, stronger engagement, and fewer errors. It is time we recognize that a happy, focused, and motivated workforce is not just a benefit to the individual it is an investment in the safety and success of business aviation as a whole. ❖
Behind the Eight Ball
If programming onboard systems is hard on the ground, it won’t get easier in the air.
DAVID JACK KENNY
Becoming a pilot requires systematic study, hours of practice, and successful completion of both written and practical exams. The standards for certification as an aircraft mechanic are even more rigorous, and appropriately so – a pilot, after all, can only jeopardize one aircraft at a time. But the only essential qualification to become an aircraft owner is a sufficiently well- stocked checkbook. Self-interest may motivate non-pilot owners to become conversant with maintenance requirements and FAA regulations, but they’re under no legal obligation to do so. The same applies to assessing the qualifications of any airmen they hire to operate the craft. Personal connections and word-of-mouth referrals can count for a lot, especially for owners not familiar with the FAA’s procedures for releasing detailed pilot records.
On the morning of Friday, February 11, 2022, a Pilatus PC-12/47E landed at the rural Hyde County Airport (7W6) in the easternmost part of mainland North Carolina. On board, in addition to the pilot, were two adult passengers and four teen-aged high school students who’d made the short flight from the Michael J. Smith Airport (MRH) in Beaufort, N.C. for what was described as a “charity hunting weekend.” The hunting was apparently good; pictures posted during the trip showed the hunters posing with the ducks they’d shot.
On Sunday afternoon, February 13, the Pilatus returned to pick them up, landing just before 13:00 local time. The students were due back in school the next day, but there was no obvious reason to hurry: following a route out to the coast and then southwestward along the barrier islands, the flight would be less than 70 nautical miles. The passengers began boarding about 13:25. One of the teens was recorded wishing for “instead of oxygen masks coming down, a deck of poker cards” so they could “play Texas hold ‘em on these tables.” Up front the 67-year-old, 3,000-hour commercial pilot was in the left seat. His 28-year-old son, a student pilot whose 97 hours included about 20 in the PC-12, was in the right.
At 13:34, the pilot announced a “straight-out departure to the east” from Runway 29 (i.e., heading westbound). Weather conditions included north winds at 10-15 knots
Lessons Learned
and 10 miles visibility under a 2,100-foot overcast. No flight plan had been filed. Twenty-eight minutes later the Pilatus crashed into the Atlantic three miles offshore in an attitude later determined to have been pitched more than 50 degrees nose-down and banked more than 90 degrees to the right. The Coast Guard located the wreckage early that evening, submerged in 60 feet of water. Recovery of the passengers’ remains and portions of the aircraft, including the engine, but not the cockpit, was completed on Wednesday. The bodies of the pilot and his son were not located. On Friday, five days after the accident, dive crews found the L-3 Lightweight Data Recorder that provided the functions of both flight data (FDR) and cockpit voice recorders (CVR).
The PC-12’s owner was among its passengers. On February 17, 2021, the 2017-model airplane was registered to the 45-year-old entrepreneur’s Delaware L.L.C. On November 15-17, 2021, the pilot completed six hours of simulator PC-12 training at SimCom. Their records list this as “recurrent” training in the “PC-12 NG.” All ground and simulator tasks were checked off with an overall grade of “satisfactory.” Further details of his make-and-model experience have not been published. The NTSB did not address the question of how the pilot and owner came to know one another, but one wrongful death lawsuit (since settled) claimed that the pilot had worked for the company that provided the airplane’s maintenance services.
His medical history is better known and somewhat complicated. On June 28, 2021, he’d been issued a second-class medical certificate under special issuance due to his history of mantle cell lymphoma, which was in remission following a successful stem cell transplant. He took daily doses of acyclovir and infusions of rituximab at eight-week intervals and reported no side effects. In August 2021 he’d suffered a back injury, received three steroid injections that failed to relieve the pain of a bulging disk, and began using oxycodone in addition to a prescribed non- steroidal anti-
ammatory. Then, in January 2022, he’d tested positive for COVID-19, which he’d attempted to treat with both hydroxychloroquine and ivermectin after an infusion of monoclonal antibodies.
During his solo return flight after dropping off the passengers on February 11, the cockpit recording captured him complaining of back pain and saying “Oxycodone is the only thing that gives me a break.” The CVR transcript from the accident flight begins with sounds described as “sniffling” and “nasally rough breathing, congested exhale,” with more coughing, sniffling, and “strained” exhalations throughout the flight.
The full CVR transcript makes for difficult reading. Just over two minutes after the unit was powered up, the pilot and his son began trying to program the flight management system (FMS), entering a cruising altitude of 3,500 feet and figures for passenger weight, cargo, and fuel load. At 13:27 the pilot asked his son to enter W95 (the identifier for the airport on Ocracoke Island) into the flight plan, presumably as a waypoint. Apparently this didn’t work. After the son said, “Sorry,” the pilot replied “We’ll get it later.” The CVR recorded the son saying, “Insert seven-whiskey- six – K-M-R-H insert activate – yeah yeah yeah,” before discussion of the flight plan was dropped while they started the engine. The start triggered a master caution tone that went on for three and a half minutes before being shut off They returned to the flight plan 37 seconds after takeoff and spent the next 12 minutes trying to put it in the system. Representative excerpts of the dialogue in the CVR recording show they struggled while the pilot contacted approach control at the Cherry Point Marine Corps Air Station at 13:37:41 to request “flight following.” Whether the Pilatus was then in visual or instrument conditions is not known. They were given and read back a squawk, advised that Restricted Area 5306A was active, and promised to remain clear. At 18:39:33 they were issued a frequency change but got no response when they checked in. They failed to notice, preoccupied instead by the airplane’s track toward the restricted area and their apparent inability to make it change course. Two overspeed alerts sounded as the Pilatus descended to 3,000 feet. They finally succeeded in reversing course at 13:43:08 and exited the restricted area. The Cherry Point controller made six unsuccessful attempts to contact the Pilatus in the meantime and issued a 4,000-foot floor to the military traffic.
“Will it let me amend in between?” – “I don’t know.”
“We’re not even – this, this thing ain’t even picking it up.”
“I don’t know what I need to do … I almost wanna take it all out and start from scratch.” – “Well, I don’t know how to do that.”
“Yeah, we’re gonna be in the frickin’ restricted area.”
“Are we goin’ right or left?”
“Well, we gonna need to do something here.”
“And we’re in it, yeah ... What in the [expletive] am I doin’?”
“I have got to get a frickin’ flight plan in this thing.”
At 13:48:27 they tried to contact approach control and realized that they’d mistuned the frequency. They reestablished contact to request the RNAV approach to MRH Runway 26. This was denied due to the activity in the restricted area. Offered the choice of Runways 03 or 08, the pilot requested Runway 08 and was given vectors and a 3,000-foot altitude assignment. MRH was reporting light rain with at least 10 miles visibility under a 900-foot overcast layer with winds from 020 degrees at 13 knots, gusting to 18.
Trouble operating the avionics resumed almost at once, the pilot commenting, “I’m way behind the eight ball … I hate it when that happens … I ain’t got my dag gone glasses, either.” The restricted area went cold as they tried to load the Runway 08 approach, so they accepted the controller’s offer to return to Runway 26 and were cleared direct to CIGOR, the initial approach fix, at 3,000 feet. Their approach clearance followed three minutes later with instructions to cross CIGOR at 1,900. For more than five minutes, though, the pilot mistook CIGOR for CIBAG, the final
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approach fix for Runway 08, prompting a heading suggestion from the controller. Almost as soon as they turned on course, they descended to 1,700 feet and received an altitude warning. The pilot’s readback of the altimeter setting at 13:58:56 was the last transmission received.
The FDR showed that engine torque was reduced for the descent and not restored after leveling off. Airspeed began decreasing about one knot per second while pitch increased by 0.1 degree per second. After a second power reduction pitch increased to 10 degrees nose-up and airspeed slowed to 109 knots. The stall warning sounded 16 seconds after the pilot’s last transmission, activating the stick shaker and disconnecting the autopilot. Airspeed was down to 93 knots; published wings -level stall speed at maximum gross weight was 95. The last two and a half minutes of the voice recording included continuous autopilot disconnect warnings, eight stall alerts, and more talk about the FMS punctuated by increasing profanity. Torque increased after the initial stick shaker activation. At 13:59:40 the pilot’s son said, “We’re sideways.” Ten seconds later torque increased to full power. The Pilatus pitched up to 31.7 degrees and slowed to 83 knots in the climb. At 2:01:07 the controller queried, “What altitude are you showing? I’m showing four thousand seven hundred climbing quickly.” Radar contact was lost less than a minute later. The last 30 seconds of the cockpit voice recording included “sink rate” and “pull up” warnings from the terrain awareness warning system, overspeed cautions from the monitor warning function, the pilot cursing, and his son shouting “Dad – Dad!”
Among the numerous comments posted online afterwards were several from experienced PC-12 pilots. One, a 63-year-old career aviator, described the Honeywell Primus Apex installed in the PC-12 NG series as “very capable, but the learning curve is steep. If you don’t completely understand the Apex system and can’t operate it in your sleep, it would be very easy to become overwhelmed by it.”
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Another, who’d flown 23 years as an MD-11 captain, was more piqued in his criticism of the Apex system, opining that it was “difficult, nonlogical, and dangerous.” (Others expressed no such concerns.)
Since not everyone finds the system intuitive, the pilot’s difficulty programming the avionics may be understandable. His decision to take off and try to resolve confusion that began on the ground after getting airborne, however – especially on a flight with a strong likelihood of entering IMC – defies ready explanation. What task gets easier after leaving the ground? Why the rush? ❖
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