The Aroma of Deference

Captain Mario Jiminez flying the Intruder

ZERO dark thirty, Tongduchon Valley South Korea – minutes to target. Speed 420 knots, altitude 300 feet. A single carrier-based A6E Grumman Intruder points North surgically utilizing its terrain-following radar while threading rain-soaked valleys, fogged filled mountainous passes and low visibility scenarios on approach to the worlds’ most heavily defended border – the infamous 38th parallel. Aboard are 12 Mk-82 500 lbs. bombs. This is serious business; surface-to-air North Korean radars are active as real-world threats and imminent physical dangers. Massive geo-political turmoil awaits any navigational, procedural or performance errors. It’s been thundering since the beginning of the hi-speed/low altitude “live-fire” training mission (theoretically perfect weather for these aircrafts’ mission profile of low -level, interdiction), yet the closer the target (USAF Nightmare bombing complex) looms, the worse the weather becomes. Now continuous lightning bolts clearly illuminate the silhouette of the jet and its two aircrew. One of them has started to sweat. In the left seat is a young Naval Aviator, a relatively inexperienced, 26-year old who as the pilot and the only manipulator of the flight controls is operationally responsible for the overall safety of flight. In the right seat as the Bombardier-Navigator is the well-seasoned senior officer and Vietnam war hero. One prefers to terminate the flight in the interest of safety, adherence to existing rules and compliance with standard operating procedures. The other crew member through body language, grunts, hand signals and time-consuming silent deferrals intends to “press on and get the mission done”. It becomes obvious that a covert difference of opinion permeates the cockpit infusing in its wake the unmistakable aroma of deference.

Deference is the condition of submitting to the espoused, legitimate influence of one’s superior or superiors. It is a yielding or submitting to the judgment of a recognized superior, out of respect or reverence. Deference has been studied extensively by political scientists, sociologists, and psychologists. Yet, most cogent to our field of aviation this definition harvests a myriad of obscured cobwebs, mouse traps, and decision-altering hand grenades.

Ground zero for detonation is based on simple differences in expectation – “Is what I expect to happen what’s really going on – are we on the same page”? At specific critical moments in time and space, any misunderstandings, assumptions, incapacities or neglect will quickly, easily and forcibly impale chards of failure and loss. While these landmines can be potentially embedded in every flight we take, the mere fact that our judgments can be altered by an outside source (someone who either covertly or with brazen gusto applies undue pressure by enforcing early time constraints and task saturations) can easily deliver significant deviations from standard operating policies and procedures. Additionally, it sets a scenario where the breakdown of effective of communication will without doubt, alter the basic chemical composition of our own, personal decision-making process.

In my life-long professional quest to become more proficient at this human factor genre, I’ve called on my experience and research to label four of them. Analogous to petri dishes, they are perfect culture-creating trays cogent to the possible misapplication of deference: leader/follower relationships, communication skills, situational awareness and decision-making.

Leader/follower – It starts on day one and it continues on every single flight. As a participant on both sides of this equation I can clearly identify with the specific roles whose effective fulfillment will eventually dictate mission accomplishment and more importantly assure the safety of flight. I have always done my best to establish clear lines which unambiguously demarcate areas of responsibility and more importantly cement that final authority. These must be identified, understood, agreed upon and adhered to, “prior to leaving earth”. As the leader, I must set the tone from the very beginning and must be consistent – if I’m at the flight controls then I make that final decision. if I am not – then I willingly grant the authority to whomever is working the stick, rudder and throttles; ensuring that the pilot does feel completely comfortable with his/her own decision-making. Written policy and procedural manuals are useful tools that can be often referenced. Yet, I found out that for me, nothing beats: “Hey, just want to remind you that today our safety is in your hands, let’s do what’s right. If you have any questions, doubts or concerns, please speak up – let me know right away, don’t forget – I’ll back you up”. This simple phrase, spoken clearly and unequivocally at the beginning of each and every flight has been my decades-long number one countermeasure against the misinterpretation of deference.

Communication – Clear, concise, unambiguous, timely – solution driven. Remember – “The greater the stress level, the more difficult communication will be”. In the presence of improper deference, accident histories clearly identify breakdowns, misunderstandings and assumptions. Clear examples are “trial balloons” – these are generally ambiguous hints, dangling participles or incomplete statements issued by the individual with the concern (in hope that the person(s) they are addressing picks up on their trend and properly interprets their meaning, all along not getting their feelings hurt or not feeling disrespected). More often than not, those “trial balloons” are in fact either misunderstood or ignored. They also eat up precious time. Keep it basic, keep it timely, try your very best to offer solutions and/or proffer options regarding your past, existing or upcoming dilemmas. Don’t just state the problem, give yourself a way out! I have always utilized key phrases such as “I’m concerned or I’m uncomfortable” as sacrosanct statements which for me, identify serious situations. If those words are spoken, it’s time for all of us to pay attention. More importantly as the person at the controls, I have to know well before the firecracker has been lit, that I can speak up without being judged. Also be cognizant of verbal (tone/inflection/interruptions/volume) and non-verbal (body language/eye contact) feedback which may very well deliver a much stronger message. Make the message the luminous star of your statement. Focus on what is right not who is right! As the listener, I always make the extra effort to validate any concerns, it could very well save our lives.

Situational awareness – Is the perception of environmental elements and events with respect to time or space, the comprehension of their meaning, and the projection of their future status. It’s a mouthful for sure, and what makes it even more difficult to master is its ever-changing nature. In simpler terms, it’s just “pattern recognition, a been there-done that” mantra. In familiar territories, we can easily, quickly and accurately adapt. Yet in unchartered waters or at the crest of a tsunami (despite our valiant and best efforts to “find our way”), the very last thing we need is the feeling (perceptive and/or real) that an aroma lingers potentially affecting our final outcome, especially an aroma that has a direct effect on our livelihood. Interestingly enough accident histories show that nearly always significant clues are available (in time) to recognize and recover – they also clearly identify errors in judgment as the leading cause of accidents, followed closely by those that are skill-based. Furthermore, the cognitive nature of the analysis required in gaining and maintaining S.A. utilizes both short-term and long-term memory banks, both of which are finite. Both are negatively affected by the bilateral stresses of criticality and time. The more complex the solution to the puzzle is, the more difficult the process will be. And as discretionary time counts down, the malignancies of “tunnel vision” are sure to yield their results. Accurate S.A. is useless if it cannot be converted into proper action, and that action has to be applied, at the right time, at the right place and in the right manner by the one “behind the wheel”. The thought that lingers is who truly is the author of that situational awareness at the moment of truth?

Decision making – Have you ever noticed how easy it is to know when someone else is making a bad decision?  We find it easier to assess someone else’s choices because we all have two views of the world – an outside and an inside view. When you think about someone else’s situation you are able to consider it from the outside – using the rational side of your mind. But when “the shoe is on the other foot” and it is a decision affecting your life the emotional side does take over. Reality is everyone’s mental “default setting”. The role of emotion in decision making is grossly underrated in the aviation community – no doubt as “real men don’t talk about such things”. Yet there is an over-abundance of evidence that emotional decision making might very well be hard at work when we are listing our options in flight. It is emotion – how we feel – that “closes the deal”, that makes that final choice. The emotional reward will be the (perceived/real) approval of his/her peers and superiors will send his/her way after one has “hacked the mission” though the going was tough. As a leader, have you ever placed undue pressure on whomever is working the flight controls and throttle? Let us not forget that “good stories are often about bad decisions”. Emotion consumes logic and drives behavior, in all of its’ righteous glory often transforms into the enemy of analysis affecting how we do process information. We then are prone to misinterpret facts, commit framing errors, take shortcuts and align ourselves with confirmation bias.  Emotion’s first cousin – subjective confidence – is the probability of being correct. It is not a judgement – it is a feeling – so, coherence of a story equals acceptance, while incoherence of a story equals denial. Surprisingly acceptance of a story (as gospel) actually requires very little quality and/or quantity, it’s much more about the strength of the delivery, emotion, passion, energy, confidence and enthusiasm with which it is transmitted. The landmine here is believing that it is actually true or correct. Trusting the validity of a story solely based on the confidence of self or others is a poor indicator of accuracy. Statistically you might as well flip a coin. So now, someone has made their mind up. Why are they saying what they are saying? Dissect it, get to the bottom of their reasoning. Ask yourself, if in fact you are in over your head. How really important is it to be right here, right now? Specifically what price are you willing to pay? It’s exactly these replies to each and every one of my questions that did in fact keep us safe on that pitch-black Korean night.

Forty-three years later this old and crusty Intruder pilot hammers away at these keys, and the sweat does come back. Why is that? Because even with amazing technological advances and modernization of aircraft, as well as a much greater skillset required of our aircrews, accidents still happen, and they do so for the same basic reasons. The dangerous aromas of deference are still taking their toll. Let us not allow those things that matter the least, affect the things that matter the most.

Mario Jimenez grew up in Colombia – South America and several Latin American countries. He has a B.S. in Business Administration from The University of Texas, El Paso. Additionally, he has attended numerous military and civilian schools in pursuit of professional development.

• From 1973 until 1983 he was a United States Marine Corps Officer as well as a Naval Aviator flying the A6 Intruder, the T2 Buckeye and the A4 Skyhawk in both land and sea environments.

• From 1983 until 2016 he was employed as an Airline Pilot with FedEx.

He led as a Captain for 24 years and facilitated as an Instructor Pilot for 12 years.

With FedEx he flew the Boeing 727, the McDonnell Douglas DC10 and the McDonnell Douglas MD11 freighters.

He has served as an advisor to Utah Valley University’s Professional Pilot Program on training and educational philosophies.

He has been a guest speaker at the Marriott School of Business – BYU

He has a 38 + year flying career.

15,000 + flight hours

During a 5-year period at FedEx he led the Human Factors Performance Group within the Air Operations Division, responsible for specific cognitive training and evaluation of 4500+ pilots. Concurrently he served as a member of the Pilot Applicant Selection Team. He is the founder of Jetstream International – a consulting firm specializing in the circumnavigation of human error. He has been married to Barbara Bluth for 45 years, they have 3 children & 11 grandchildren. He and his family have resided in Utah since 1999.

Aircraft Accidents and Lessons Unlearned XLIII: JetBlue Airways Flight 292

JetBlue flight 292 during emergency landing in Los Angeles airport

On September 21, 2005, JetBlue Airways, registration number N536JB, flight 292 landed at Los Angeles International Airport (LAX) with its nose gear wheel turned ninety degrees from center. The Airbus A320 departed Burbank airport headed for JFK airport in New York. The flight crew flew the aircraft for close to three hours to burn off fuel for the emergency landing; the decision to divert was made after the unsuccessful retraction of the nose landing gear (NLG) because the NLG tires blocked the gear from folding into the wheelwell. The two main gears, meanwhile, operated normally.

National Transportation Safety Board (NTSB) accident investigation, LAX05IA312, did not go through the normal investigatory process – it is assumed – because there were no casualties; the aircraft was not destroyed. As soon as the media blitz ended, complete with helicopter vantage point coverage of the edge-of-one’s-seat landing, the accident was put to the back pages. This was an unfortunate mistake; an aircraft that survived an accident would have been a teaching tool like no other. Six years earlier, a US Airways Airbus A320, flight 1549, survived its accident mostly intact. However, just like JetBlue 292, the NTSB missed important information in that accident and then failed to follow up on crucial findings that were instrumental to the industry.

The report was confusing; the terminology was ambiguous. Because of Airbus’s excessive use of sensors in the NLG steering and positioning, the reader, in order to understand what was happening, should have had a better narrative. For instance, when describing the proximity sensors, the report states, “There are a pair of proximity sensors and targets on the NLG that detect if the gear is extended (airplane in air) or if the gear is compressed (airplane on the ground).” When a gear is deployed in flight, it is considered ‘extended’, ‘retracted’ when up in the well. Instead, the report used ‘extended’ to describe the strut as extended, not the gear. Also, the ambiguous use of, “… a pair of proximity sensors and targets …” does nothing to aid understanding of what sensors/targets, how many sensors/targets are used, when during the deploy sequence are they required and for what purpose.

In 1966, Star Trek (the original series) relied heavily on storyline, not limited technology computer graphics (CG) to be successful. Common sense overrode technology. In contrast, 2017’s Star Trek: Discovery relied heavily on CG – not storyline. Technology replaced common sense. The successful franchise wasn’t broken, so why did they ‘fix’ it?

Today, technology has become the digital aircraft’s prominent characteristic, while reliable decades-old technologies are dismissed. The extensive use of technology does not make aircraft systems unsafe – it makes the systems unpredictable. For instance, the JetBlue 292 accident report mentioned that the A320 employs a device called the Brake Steering Control Unit (BSCU); it electronically controls the aircraft’s steering system. One BSCU function is to perform four bite tests – four deflections of the NLG steering through five degrees of travel … left to right … in flight … before touchdown. Why? Why test the steering before landing? Could this bite test have contributed to JetBlue 292’s misaligned nose strut?

Before digital wire technology, steering was simple; it was accomplished via a series of cables, pulleys and bellcranks. The steering system was not heavy because it ran from the NLG to the Captain’s steering tiller directly above. This system always worked; there was no need to test the steering in flight. The fundamental steering system design wasn’t broke – why fix it? Airbus, by employing numerous sensors and targets, ‘corrected’ a system that worked; they fixed the system beyond all repair.

Meanwhile, NTSB investigators were so caught up with the technology, that they forgot to check a most important factor: Was the NLG strut properly serviced? The gear’s integrity was intact – the strut, uncompromised; they could have checked. The NTSB docket for LAX05IA132 had nineteen specialty reports and documents; not one answered the simple question of strut servicing. The JetBlue 292 accident report did not answer that question either. Why, then, is strut servicing important?

NLGs, since the dawn of tricycle gear use (a nose gear and two mains) have used a mechanical device called the centering cam. The NLG shock strut has three main parts: a piston (chrome strut), an upper cylinder body (the sleeve the piston slides in; it connects to the aircraft) and the scissor links, which, among other things, prevent separation of the piston and cylinder body. Centering cams, also called locating cams, are mechanical devices located inside the strut. A locating cam (LC) is a simple design; each pair resemble two sine waves that slide together when employed. There are two LCs: an upper and a lower. As the aircraft rotates, weight comes off the NLG. The strut’s nitrogen pneumatic charge immediately pushes the piston away from the upper cylinder body. The upper LC on the piston engages the lower LC attached to the cylinder body, which aligns the gear to the aircraft centerline. Simple.

The A320 has centering cams. They work … but only as long as the strut is properly serviced with nitrogen to force the upper and lower LCs to engage. The accident report did not verify JetBlue 292’s NLG had the proper nitrogen charge. The centering cams would have made the sensor/target technology irrelevant in lining up the NLG to the centerline. Was the NLG strut properly serviced?

Unfortunately, in its inexperience, the NTSB did not understand this. Instead, they focused on cracks found on the NLG’s upper support assembly’s four lugs; damage from NLG stresses during landing. The four lugs did not contribute to the gear strut turning ninety degrees from the centerline, so this begs the question: Who cares? Why examine damage made after the landing? The purpose of an accident report is to highlight the cause(s) that led to the accident, not what was incurred after.

Furthermore, the NTSB spent great effort analyzing sensors and targets that – maybe – contributed to the accident yet did not produce a viable solution to any problems they may have caused. To slightly alter an Abba Eban quote, “The [NTSB] never misses an opportunity to miss an opportunity.”

Here are two examples of why maintenance-experienced investigators – specifically, airframe and powerplant certificated maintenance investigators with experience working in the industry – are critical to the NTSB investigatory process. First, a practical problem: It appears (because the NTSB did not provide NLG strut servicing evidence) that important clues were missed prior to flight. Was the strut ‘showing chrome’; in other words, was the strut flat, deflated, not serviced properly? This would have been caught by (hopefully) two individuals: the mechanic assigned to the flight and the first officer during his/her preflight walkaround. A flat strut would have been evidence of the strut requiring servicing or a leak. If the strut was properly serviced, again, the inflight emergency may not have happened. This would amount to an operational problem at JetBlue, a procedural revision of their manuals.

Second, a technical problem. The NTSB identified an unknown number of sensors and targets that track just the NLG’s movements, such as deployment, retraction, inflight steering tests, up-and-locked or down-and-locked. The consequence of the technology, as stated, “… a failure condition can exist that results in the NLG system sensing ‘ground/compressed’ when the gear is extended and a mechanical failure allows the NLG wheel to rotate to a position greater than 6 degrees.” The report confused ‘extended’ with down-and-locked/ strut at full travel; the “NLG wheel to rotate” should have been written “strut turned – or steered –  to a position greater than 6 degrees”. One can see how JetBlue 292’s strut turned ninety degrees from centerline; the still rotating wheels caused vibrations that helped the airstream turn the strut beyond the allowable six degrees in a few seconds.

With numerous sensors and targets, Airbus created multiple-point failure opportunities. There are too many sensors and targets, which lead to: (1) countless chances for computer error, and (2) numerous occasions for these sensors/targets to become damaged in day-to-day use, which, again, leads to computer error. The fact that the strut was able to rotate beyond six degrees should have raised multiple flags. It should have caught an experienced eye and acted on.

No accident, whether survivable or not, is too small or insignificant. What information was lost and could have been learned by JetBlue 292 cannot be emphasized enough. Investigations large and small demand qualified investigators that can identify problems and fix them. The traveling public deserve better.