How to make flying safer?
China News Weekly reporter / Huo Siyi and Cao Ran
Published in the 1038th issue of "China News Weekly" on April 4, 2022
Guy Hurst, retired captain of British Airways in his 70s, has experienced the most brutal period of growth in the global civil aviation industry.
It was in the 1960s and 1970s, and the technology of jet airliners was still gradually maturing. The design flaws of large airliners from the Comet to the DC-10 continued to trigger air accidents, and the guarantee conditions were backward.
He once drove an old plane with a broken engine from Hong Kong all the way back to London for maintenance.
Half a century later, the global aviation industry's "fatal accidents per million flights" recorded by the Flight Safety Foundation has dropped to 0.51, a 12-fold decrease from the 1970s.
However, people are still dissatisfied with 0.51 times. In the pursuit of "infinitely close to 0" the number of safety accidents, with pilots as the center, airlines, manufacturers, regulators, etc. are trying to build a whole-process safety net, They hope that from before takeoff to after landing, no one is injured or killed, and people can see their family and friends waiting at the airport smoothly.
According to ICAO's 2021 Safety Report, the five major types of serious aviation safety accidents in recent years are controlled flight into terrain, loss of aircraft control, mid-air collision, runway deviation and runway incursion.
In 2020, they accounted for more than 50% of fatal aviation accidents worldwide.
Simulator training: "This manual is not all-inclusive"
On the glass in front of the cockpit, the blue sky and the runway outside the window are reflected. The blue sky has no impurities and looks a little distorted.
Inside the cabin, various data on the top panel and instrument panel flickered and jumped in the dimly lit environment.
After all pre-flight setups are complete, one hand of the pilot is placed on the thrust lever and the bank is banked to one side at a slow, gentle pace.
The slope is climbing as planned.
The hand holding the handle began to sweat slightly.
Through the perception of some tiny mechanical vibrations, he confirmed the changes in the state of the aircraft little by little. This is the main difference between Boeing series aircraft and Airbus: to control this behemoth by mechanical rather than telex, the pilot's control technology is in a state of The most central position in the series braking.
When the needle pointed to 10,000 feet, the plane was entering a calm cruise.
Suddenly, the warning lights flashed, the buzzer sounded, and the plane began to pitch violently: there is an emergency!
At this moment, an experienced pilot will quickly calm down, first control the attitude of the aircraft, and at the same time determine the cause of the failure, and check according to the procedure.
Some novices may panic, blank minds, and watch the plane spin and crash to the ground.
However, he did not die.
None of this is actually happening, but a virtual training scenario in a full-motion flight simulator.
The Civil Aviation Administration of China stipulates that every six months, the pilots should conduct a recurrent training on the simulator, and each training should last at least 12 hours and be completed in three sessions.
In this white cabin, which weighs about 13 tons and can be shaken in 6 directions, pilots will experience extreme weather such as rain, thunder, lightning, fog, snow and frost, as well as engine failures, bird strikes, cargo hold fires and mid-air collisions. Wait for various emergencies that may be faced during the flight.
But extreme situations in real flight can be trickier than in a simulator.
For MU5735, which had an accident on March 21, according to the final attitude of the plane crash in the video of Beichen Mining Company and the winglet debris found 10 kilometers away from the core crash site, Chang Ping, a senior captain who had worked in China Eastern Airlines Yunnan Company Speculated to "China News Weekly", "The pilots may not know what procedures to take in this situation."
After a pilot graduated from aviation school enters an airline, he starts as a co-pilot and improves his skills through the accumulation of flight time. At least 2,700 hours of accumulated flight hours are eligible for promotion to captain.
However, Zhang Ke, a senior captain who has served as an executive in many airlines, pointed out to "China News Weekly" that the pilot's ability to deal with special situations is not directly related to the flight time, because for most pilots, they have never faced a lifetime. In the event of an emergency, "20,000 hours of flying and 30,000 hours of flying are not much different."
How to make real flying safer?
The answer is not in every aircraft takeoff and landing, but in daily training, flight training is the basis for ensuring the safety of aircraft operation.
Zhang Ke is very familiar with the current situation of domestic flight training. He pointed out that for the same aircraft type, the simulator training content of various Chinese airlines is similar, and they all revolve around the "manual", that is, a set of program operation guides. These programs are based on aircraft The manufacturer's flight manual is based on the operating experience of various airlines in dealing with faults over the years.
But the procedures that are not in the manual do not mean that the pilot cannot do it, nor do they need to learn it, because the various special situations that may occur in reality are far more than what can be covered in the manual, and the reasons are often more complex. complex.
For example, in an extreme case, the aircraft suddenly fails with both engines, that is, both engines lose power and plummet to a height of 200 meters above the ground. In such a near-ground emergency, how to restart the engines, Keep the plane from hitting the ground?
"I was training a crew once and no one could answer what I was going to do and what the procedure was. Although it's true that dual engine failures are extremely rare in reality, it's an emergency procedure that saves lives because there's nothing in the manual. It is impossible to demonstrate to the pilot on the simulator." Zhang Ke said.
Air crash history often shows that training beyond the manual is necessary.
From 2018 to 2019, the Boeing 737 MAX airliner had two consecutive air crashes, killing 346 people. The survey shows that Boeing has revised the flight manual in order to increase its attractiveness to customers and reduce the training cost of airlines. The new version of the manual There is no mention of the new Maneuvering Characteristics Augmentation System (MCAS) for the aircraft.
The two air crashes happened precisely because the crew could not get correct guidance from the manual after the passenger plane suddenly triggered the MCAS system.
In September 2019, the National Transportation Safety Board (NTSB) noted in its review of the system that, for a long time, both the aviation industry and the FAA had developed manuals under the assumption that "trained test pilots would Immediate response", that is to say, the default pilot is an experienced senior captain who can fully respond to various emergency extreme situations.
Zhang Ke analyzed that this standard is too high and does not take into account the different abilities of different pilots to deal with special situations.
This also shows that the manual is not a panacea.
In fact, Boeing's flight manual for China even added a sentence: "This manual is not all-inclusive."
After being named and criticized by the NTSB, Boeing updated the content of MCAS in the revised manual, but the economic factors of "reducing training costs and attracting airline users" have made "first out of the plane crash, then into the manual" a long-term stubborn problem. MCAS is just the latest case exposed.
Zhang Ke pointed out that the airline's training plan should be carried out under the unified supervision of the Civil Aviation Administration, and only the subjects specified in the "manual" can be trained on the simulator; on the other hand, although the content of some of these subjects has also been updated, in fact Change the soup but not the medicine.
In general, the independence and autonomy of airlines in training is very low. For example, if a pilot completes all planned subjects in advance within the prescribed recurrent training time, the instructor cannot carry out the training for him in the remaining time. Add extra training and do some subjects outside the manual.
"These are not conducive to improving the pilot's emergency response ability to special situations, because their training is not targeted." In Zhang Ke's view, the technical level of the captains varies considerably.
On June 21, 2019, the Civil Aviation Administration of China issued the "Guiding Opinions on Comprehensively Deepening the Reform of Flight Training for Transport Airlines", which clearly stated that the requirements in flight training should be consistent with the actual operation requirements, and the flight simulation training should be The environment and scenario settings should be closer to the real operation.
The relevant person in charge of the Flight Standard Department of the Civil Aviation Administration has publicly pointed out that we have found that the frequency of "black swan" events, which are extremely unlikely, has increased in recent years. Love happens from time to time.
Taking the "Sichuan Airlines 3U8633 Incident" as an example, on May 14, 2018, Sichuan Airlines flight 3U8633 was cruising in the Chengdu area, and the front windshield of the right seat of the cockpit suddenly burst and fell off. This is an aircraft the crew has not encountered in previous training. Fault.
In this regard, Zhang Ke suggested that it is possible to consider adding 15 minutes of instructor-selected subjects to each recurrent simulator training, to improve the flexibility and freedom of training pilots, and to add some emergency handling procedures outside the manual.
Guy Hurst, senior captain of British Airways, is also concerned about a phenomenon.
He pointed out to "China News Weekly" that the new crown epidemic has caused pilots from various countries to lack the opportunity to actually fly. "Simulators are very expensive, and we don't have enough simulators for every pilot." Some pilots have not flown for several months. "As a pilot, you have to think and review flight knowledge during this period, but this is not so intuitive, and in the context of the epidemic, it is difficult for people to pay attention to these issues, which will lead to an increase in some small safety incidents, which may eventually lead to a major accident.”
human factor
"What makes someone who is already very skilled make a serious mistake in flight, or an extreme situation where it is irreversible that is technically salvageable?"
In the 1980s, Hirst began to ponder this question.
He originally thought that simulator training was the most important means of ensuring safety.
The civil aviation industry at the time believed that if people were technically very good at flying, they would be able to effectively handle all kinds of emergency situations, and flying would be safer.
But in 1977, the deadliest air disaster in human history occurred - the Tenerife air disaster.
Investigators found that when the captain of KLM Flight 4805 rushed to take off without listening to the tower's instructions, the rest of the crew did not dare to alert the captain that there was another plane on the runway.
The investigation report pointed out that the reason may be that the captain had already shown a state of anxiety before takeoff, and he himself was the chief flight instructor of KLM, which made other crew members fear.
This miscommunication, combined with other factors, eventually led to the deaths of 583 people.
Hirst was a training captain for British Airways' Boeing 747 and other wide-body aircraft before retiring, and served as a flight safety training standard setter for the British Civil Aviation Authority (CAA) and British Airways.
He pointed out to "China News Weekly" that in addition to technology, another key issue is the team strength of the crew. "The state of the team is as important as the state of the aircraft and the state of the weather."
A series of air disasters in the 1970s made the civil aviation industry realize that each pilot has different skills, different preferences, and when they are combined in a crew, how to quickly and effectively build a team that can deal with all situations is to obtain The key to flight safety.
Initially, Hirst tried unsuccessfully to persuade captains to change behavior and improve crew communication within the old training system.
As a result, he and a group of civil aviation industry veterans first introduced the concept of Human Factors and Crew Resource Management (CRM) into the training systems of major European airlines in the 1980s and 1990s.
In the following two decades, countries including China have changed the traditional concept of flight safety management and began to consider "human factors" more.
Air accidents related to crew resource management are mainly manifested in two types. One is that the co-pilot did not express his opinion to the captain in time, which caused the captain to fail to notice his mistakes; the other is that the crew members fully expressed their opinions. , but the captain did not listen to and judge these opinions in time.
From the 1980s to the present, more than 20 serious air crashes have been identified as human factors in insufficient CRM training.
Accidents at some top airlines in recent years have led investigators to warn that CRM and human factors issues are not getting enough attention globally.
After the Air France 447 crash in 2009, investigators found that there was also the problem that "anyone in the crew had no idea (in an emergency) who was responsible for what and what the others were doing".
"At least in the airlines I have trained, CRM is already part of the first officer qualification assessment, and it can even be said that in a future where aircraft flying is increasingly automated, good team skills are more important than knowing how to fly a plane proficiently." Hurst said.
In China's civil aviation safety management, we are increasingly aware of the importance of "human factors". In the regulatory documents issued by the Civil Aviation Administration of Establish the pilot's "core competency", "psychological competency" and "style competency".
Among them, the most important is the concept of "core competency", which includes technical and non-technical levels. There are four indicators of technical competence and five indicators of non-technical competence, including communication, leadership and teamwork, decision-making, Situational awareness and workload management.
The indicators of ability can be refined, but in actual management, the management of people is far more complicated than this.
Monitoring the mental health of pilots, for example, is a global challenge.
After the accident of Germanwings flight 4U9525 caused by the suicide of the co-pilot, the international solution was to mandate the presence of two crew members in the cockpit to avoid a single-person suicide.
But there are no clear solutions to other problems, such as slowing of reflexes induced by mental health problems.
The European Union of Psychologists issued a statement after the aforementioned air crash, calling on airlines to conduct psychological testing when selecting pilots, which has become an international practice, but the society also said that each pilot's life events and mental health problems are unpredictable .
At present, there are two common international practices. British Airways will have professional doctors to conduct mental health assessments on pilots during the semi-annual health check, while Lufthansa and other airlines adopt the method of random psychological examinations by professional doctors.
But Hirst points out that there are always people who want to hide their psychological problems.
At British Airways, pilots are assessed on mental health by doctors during semi-annual health monitoring or physical examinations.
In China, airlines also conduct regular medical examinations for pilots, usually once a year, and six months a year over the age of 40. The older you are, some additional items will be added, but these tests do not include professional mental health tests.
Several captains pointed out to "China News Weekly" that the pilot's psychological counseling mechanism still needs to be strengthened in China.
Some domestic airlines have regular one-on-one psychological conversations, but they are not professional mental health assessments. They mainly talk to pilots about family conditions, difficulties encountered in flight, and recent ideological developments.
After the epidemic, flights were restricted.
The "2020 Civil Aviation Industry Development Statistical Bulletin" released by the Civil Aviation Administration of China in June 2021 shows that in 2020, the industry-wide transport airlines completed 8.7622 million transport flight hours, a decrease of 28.8% over the previous year.
Among them, 879,900 flight hours were completed on international routes, down 63.3% from the previous year.
Among the "three major airlines", the passenger traffic volume of Air China, China Eastern Airlines and China Southern Airlines decreased by 36.7%, 42.7% and 36.1% year-on-year respectively.
Some people in the industry said that after the epidemic, the flight hours of front-line pilots plummeted, from 80-90 hours per month in the past to 30-40 hours now, and the current work environment with strict safety supervision has also changed their psychological burden. heavier.
Take the "QAR monitoring project" as an example, the full name of QAR is the fast recorder, which can continuously record up to hundreds of hours of raw flight data, including thousands of parameters such as altitude, speed, attitude, acceleration, etc., covering all aspects of aircraft operation. Therefore, it can not only be used as the basis for accident investigation, but also be used to monitor the pilot's flight quality in real time.
Based on these data, airlines can monitor information such as the take-off ground angle of the fleet, the distance from the ground at the tail when taking off, the height at which the landing shape is established when landing, and the landing overload, etc., to check whether the fleet as a whole has bad operations. Habit.
In the late 1990s, the Chinese civil aviation industry began to implement QAR records.
In 2012, the Civil Aviation Administration promulgated the "Flight Quality Monitoring (FOQA) Implementation and Management", which formally put forward requirements for airlines and flight quality monitoring projects. "Monitoring base stations", and uniformly receive QAR data of civil aviation aircraft every day.
The aforementioned pilot pointed out that the Civil Aviation Administration will set a "lower limit" for these monitoring indicators, but in practice, each airline company, even each branch company, and the flight group will "overweight" this standard.
"For example, the aircraft should not be too 'heavy' when it lands, otherwise it will affect the stability of the overall structure of the airframe. Therefore, an important indicator in the QAR monitoring project is the landing load of the aircraft. The standard parameter is 1.6G. Under this, it will not affect the safety. . But some airlines will increase the code to 1.4G, or even 1.3G, which is a standard that is too strict for pilots. Once pilots fail to meet this standard, they will be warned or punished, and may be banned from flying in severe cases.”
In fact, in a document issued by the Civil Aviation Administration in 2012, it was clearly stipulated that airlines monitor QAR data in order to identify potential hazards in a period and improve them, and QAR data should not be used as an information source to punish a specific pilot.
Safety is continuous hazard identification
and risk management process
Zhang Ke remembers that in the 1980s, the safety situation of China's civil aviation was far worse than it is today. The main problem at that time was the backward hardware conditions. Many airports were not equipped with "instrument landing systems" (commonly known as "blind landings"), and the civil aviation aircraft that were involved in the accident were also Most of them are Soviet-made passenger aircraft and Trident passenger aircraft with a long design time and a long service time.
In 1995, the Ministry of Labor compiled the "Typical Cases of Major Injury and Casualty Accidents in Industrial Safety and Health at Home and Abroad", when summarizing the flight accident of Southwest Airlines Flight 4146 that killed 108 people in 1988, it pointed out that there are many aircraft types and rapid development, resulting in a lack of aviation materials. Personnel training, ground supporting facilities, communication and navigation equipment and other aspects cannot meet the requirements, which brings many difficulties to technical management and quality control, and produces many unsafe factors.
But the more important problem is that the rules are not perfect.
"It should be said that the turning point occurred in the early 1990s. China's civil aviation industry gradually eliminated old models by introducing Boeing and Airbus aircraft, and carried out legal construction." Zhang Ke pointed out.
In September 1992, the Civil Aviation Administration issued the "Order on Ensuring Flight Safety", which for the first time clearly and completely put forward the basic principles of "eight should and one objection" that the industry has followed up to now, that is, the go-around that should go around, and the cloud that should go through the clouds. , The return flight that should be returned, the alternate landing that should be alternated, the circumnavigation flight that should be flying around, the waiting that should be waiting, the reminder that should be reminded, the action that should be done, and oppose blind and reckless actions.
Since then, the safety management of China's civil aviation has been gradually standardized, but around 2000, there are still many problems in the implementation in various places.
An old captain who once worked for an airline company in the southwest region recalled to China News Weekly that the simulator training time was occupied, the monthly limit was exceeded, and the captain was afraid of missing the timetable and did not carefully check the checklist, etc. It was more common in those days. "These kinds of phenomena have been reduced a lot in recent years, but at that time, just before the second round of civil aviation system reform, due to historical reasons, the bureaucracy of airlines was still very heavy."
Since the reform and opening up, China's civil aviation industry has undergone three major reforms. Li Jun, former deputy director of the Civil Aviation Administration and chairman of the China Air Transport Association, once wrote an article to introduce that the first round of reforms took place in 1980. The second round of reform was basically completed by 1992, realizing the separation of government and enterprises, and the independent operation of airlines, which changed the situation that the operation and supervision were not separated; the third round of reform at the beginning of this century was Focus on corporate restructuring, decoupling from the civil aviation industry management department, and realize group operation.
The former Yunnan Airlines was placed under the banner of China Eastern Airlines, which is part of this reform.
After the three rounds of reform, a three-level management system has been implemented for national civil aviation safety, namely, the Civil Aviation Administration of China is responsible for guiding and supervising civil aviation safety work across the country. The Civil Aviation Supervision Bureau of each province, autonomous region, and municipality directly under the Central Government supervises the local civil aviation safety work.
However, Zhang Ke pointed out that under such a three-level management system, in some areas, there is a problem of overlapping management. "This is also one of the reasons why some local airlines have greater pressure on safety management."
The data as of February 19, 2022 shows that the continuous safe flight time of China's civil aviation transport aviation has exceeded 100 million hours, creating the best new safety development performance in the history of China's civil aviation and the best continuous safety in the history of the world's civil aviation. flight records.
In the past five years, the 10,000-hour rate of China's civil aviation liability and serious liability warnings has been the lowest in history, and the quality of safe operation has continued to improve.
Hirst pointed out that in order to achieve flight safety throughout the process, the following points need to be paid attention to: First, we strive to avoid mistakes, obtain accurate trim, weather and other information through good briefings, acquire skills through good training, healthy body.
In the next stage, we as a team can point out and correct each other's mistakes.
Finally, if something goes wrong, try to mitigate the consequences as much as possible.
If you miss the runway on the approach and landing, go around and try again.
From the perspective of an airline, in Hearst's view, a safe airline is not about creating the kind of hero who takes passengers to escape at the last minute, but about ensuring the safety of the whole process and all the time. .
This means that a lot of times you have to give up what the business is after, such as when you need to go around, your pilots have to be able to go around decisively, although this may cause passenger delays, but at this time you have to give up the consideration of efficiency.
The benefits and economic considerations that affect safety are all traps and things we want to avoid. This is the management strategy of airlines.
The safety community has an "incident pyramid model" that arranges a set of data: 600 "incidents with no injury or damage" → 30 "incidents of property damage" → 10 "incidents with serious injury" → 1 "significant incident" or fatal injury".
There is an important aviation safety concept here, that is, any major aviation accident is composed of a series of small accident chains without a single cause and effect, and an incident is the "eye" for monitoring the occurrence of major safety events.
China's "eye" is the industry standard for "Civil Aircraft Incidents" promulgated by the Civil Aviation Administration. It lists six categories and more than 100 specific types. It is the main standard for the Civil Aviation Administration and various airlines to evaluate, identify and handle safety incidents. .
Zhang Ke pointed out that the standard is based on internationally accepted standards, which is scientific and reasonable in itself, but there is still room for further refinement in the specific implementation.
"For example, the standard mentions that hitting an obstacle during take-off and landing is an accident, but how is the obstacle defined here? There is still no unified definition."
When conducting incident statistics and safety assessments for aviation companies, the indicator of "10,000-hour incident rate in the current year" has been used in the past, that is, the number of incidents occurring in an airline's fleet per 10,000 flight hours is used to assess the safety of an airline. sex.
However, Zhang Ke pointed out that for large airlines with hundreds of thousands of aircraft, it is easy to fly in 10,000 hours, but for small airlines with only a few passenger planes, the 10,000-hour rate indicator is very difficult. evaluate.
In March 2022, the "Deepening Civil Aviation Reform Evaluation Team" composed of members of the General Department of the Civil Aviation Administration and other departments issued a "2021 Evaluation Report on "Improving the Aviation Safety Management System", proposing that enterprises should be monitored for five years (or three years). Years) rolling value, maturity of safety management system, actual monitoring data and other parameters to replace the current year's 10,000-hour rate index.
In Zhang Ke's view, this new proposal is more reasonable, because the use of multiple indicators instead of a single indicator also means that the Civil Aviation Administration's safety supervision of airlines is more refined, "However, it can be more dynamic, such as every 1 to 2 years. Assess a rolling value of symptoms for a business.”
Li Jiaxiang, the former director of the Civil Aviation Administration, pointed out in 2009 that it is necessary to have a scientific and accurate understanding of the word "safety".
ICAO defines "safe" as the state in which the risk of personal injury or property damage is reduced and maintained at or below acceptable levels through an ongoing process of hazard identification and risk management.
The Civil Aviation Administration of China issued a notice on March 22, requesting that on the basis of the previous industry safety supervision work, a 2-week industry safety inspection should be carried out immediately to strengthen the investigation of potential safety hazards in the field of civil aviation, ensure the absolute safety of aviation operations, and ensure that people Life is absolutely safe.
The scope of this industry inspection includes regional air traffic control bureaus, transportation (general) airlines, service guarantee companies, airport companies, and flight training institutions. The inspection work will focus on safety thinking, professional team building, and regulations. Carry out "six investigations" such as standard implementation, safety management chain, safety assurance capability, and safety responsibility implementation.
(At the request of the interviewee, Zhang Ke and Chang Ping are pseudonyms in the text)
"China News Weekly" Issue 12, 2022
Statement: The publication of "China News Weekly" manuscripts is authorized in writing