Gary Brown about to trust his family’s life to a pair of Southwest Airlines pilots.

Observations of a SWA Line Captain

Airline safety is a continual defense against multiple threats: interruptions, weather, apathy, complacency, fatigue, mechanical failures, difficult personalities, stress, system design and more. We build armor in levels: pilot skill, knowledge, automation, procedures and standardization are some of the most effective methods at breaking deadly chains wrought by attacks of circumstance.

The captain may be ultimately responsible for a flight, but it’s up to those who design the system to build improvements at all levels and to be realistic in their expectations of the frail humanity putting them to practice.

The Cost of Safety

The best practices preserve as much safety as humanly possible within reasonable cost. Our reality is that we must weigh safety measures by their cost and benefit. We could cut the number of allowed pilot hours in half and safety would be increased by some amount. We could require airbags at every seat, double the number of flight attendants, install less flammable interiors, lighten the allowable weights for airliners (carry fewer people) to improve runway margins and many, many other things. Added together they would price the airline out of business. Even if all the airlines complied, overall traveling safety would decrease by sending people to their far, far more dangerous personal cars.

But there are some things that cost almost nothing (in relative terms) and have some measurable benefit. Not dramatic, to be sure, but a value seemingly well worth their expense.

Cost Per Life Saved

It doesn’t sound appealing but it’s a necessary calculation. If a million dollar improvement will save 1 life than the cost of the improvement is a million dollars per life. If a 100 million dollar improvement saves 1000 lives then the cost is $100,000 per life saved. The more expensive option turns out to be the better deal.

What if a billion dollar improvement saves 10 lives? That’s 100 million per life saved. Since ticket prices must increase to cover the extra cost, some passengers will revert to less expensive and more dangerous travel modes—overall transportation safety will decrease.

Sometimes safety improvements come from very expensive systems and other times they are merely procedural. Just because a system is expensive doesn’t mean it will be expensive per life saved. If it’s very effective then it may be worthwhile.

Examples abound. Southwest Airlines in 2013 or so undertook a project looking at the reality of line operations and set to improve it. Seeing the process firsthand was refreshing. They avoided saying “we’ve always done it this way” but rather made improvements to procedures that worked—not just what sounded good on paper. They should be applauded. The changes cost money by delaying initial taxi. Accidents are too rare for trend analysis and so they concentrated on other metrics, fixing what they could. Although the process was expensive, most of the changes were not. They continue this practice. 

But there are certainly other areas with room for improvement as posts in this category suggest.

1. Reducing Simple ATIS Read Errors

Anything we can to reduce pilot workload in dynamic situations, including taxiing, will improve safety. One area is how ATIS (Automatic Terminal Information System) information is recorded and presented to the pilot. Pilots should always be able to look in the same place every time for information. Milliseconds are meaningful when taxiing an aircraft. It’s not enough for management to tell the captain to “just ask.” The fact is that captains will occasionally look at the ATIS sheet for various information from closures to gate to altimeter setting.  Do we want them slurping up precious seconds hunting for that info?

Another reason for standardizing placement of the information is that it reduces the possibility of confusing data. That has happened to me before.  Most at risk is confusing the temperature/due point, altimeter setting and winds.

The solution was fortunately incredibly cheap and simple—a standard form. It puts data is in the same place every time and uses human factors layout concerns to make the data elements obviously different, even in low light. Pilots don’t spend valuable attention trying to decipher it. While the form (see below) is certainly best, just standardizing the layout of the data would accomplish a lot.

Consider the above examples. The left one was pulled off an airplane that I took over, the right one done as an example. This seems clear enough. But notice how the winds, temp/dewpoint and altimeter setting were written—with a dash. And this is common. 12 – 02 and 29 – 70. 

Now consider when the temperature is 30C and dewpoint 26C, not uncommon in the summer. The pilot, looking at such a napkin, would see 30 – 26 (temperature/dewpoint) which looks a lot like the altimeter setting of 30.26. It was exactly this error that caused a 500′ deviation on one flight (see STL example above) and motivated me to develop the ATIS Sheets in the first place. That napkin suckered two reasonable pilots into misreading it. 

The ATIS form is designed to separate the elements in very clear ways using shapes that are easily discernible even in low light conditions.

While the amount of extra time it saves is small, it frequently comes during critical flight phases that may be the difference between catching something or not. Having a dedicated form like this is ideal, but the least that should be done is putting data in standardized places to minimize potential confusion. For example, if napkins are used, the altimeter setting should always be in one corner, the same corner, and winds in the  opposing corner. It must be standardized across the airline in order to be effective.

Yes, the benefit is small, but so too is the effort/expense. It may take a billion flights to score a “save,” but with the miniscule expense, it would be an easy chink to have in the armor.

This improvement has been adopted by my airline in an ingenious fashion. I wish I’d have thought of it. They are printed on an unused section of our weather packet. It requires no extra paper meaning the cost is almost incalculably small (toner).

2. Obvious Knobs

Mode Control Panel with Tapered airspeed knob and obvious heading knob

This Mode Control Panel (MCP) is well engineered. The primary knobs used to control the plane’s flight path are uniquely shaped so they are less likely to be confused, even if the pilot is looking elsewhere as he uses them. The new one below uses the same shape knobs for everything. A distinct step backwards.

Mode Control Panel on newer 737’s

This panel is how you tell the autopilot what to do, with knobs for airspeed, heading and altitude. When I first used the 737-300’s, I was impressed with how the knobs used shape to clearly differentiate them. It was hard to twist the wrong thing. If you put your hand on the cone-shaped airspeed knob it was nigh impossible to confuse it with the mushroom-shaped heading knob which was obviously different from the cylinder-shaped altitude knob. Brilliant! These were designers who obviously understand human-factors (i.e. frailties).

Then came the Boeing 737-700 with its new MCP. Amazingly, those obvious shapes were missing, replaced with the same size cylinder knobs that varied only by their texture–a far less obvious clue. That, in my opinion, was a significant step backwards. 

Practice has shown that indeed I have twisted the wrong thing a couple times. I’ve always caught it by looking up but why add the risk? The fix is cheap and easy—go back to the previous and more obvious method.

3. Noticing Notams 

It’s not missing the forest for the trees, but rather picking out the one tree that matters in a forest of like-looking siblings. This almost bit me once on a runway who’s last half was closed, a fact that I missed while perusing 2 pages of nearly irrelevant notices to airman (NOTAMS).

FAA Notam Original

FAA Notam Modified

The top NOTAM is one of several dozen that a pilot gets for LAS. The bottom one is the same NOTAM formatted in a way that pilots can read easily. While it may use more paper, the whole exercise is pointless if pilots are ignoring them. All NOTAMs should be formatted like the lower one to improve clarity and dramatically increase the use of this important resource.

NOTAMs, of course, explain special circumstances that may be important to pilots. There are several significant problems with the system and these problems have contributed to accidents and close calls. The tragedy is how easy these problems could be corrected.

1. The part of the airport affected gets lost in the time stamp. Yes the time stamp is important, but why wade through all that clutter only to determine it doesn’t apply to you? One or two seconds per NOTAM item may not seem like a lot until you get to an airport with 20 or 30 NOTAMS and you’ve got 7 minutes to push. Of course you should just slow down but the reality of humans is that most pilots will justify skipping the novella by saying they’ll look at it in flight which means they’ll probably be skipped.

2. Put the most relevant NOTAM’s at the top. Start with runway closures then go to Taxiway closures and, if your airline has the capability, prioritize only those taxiways you’re actually allowed to use.

3. Make them obvious by how they’re indented. This can improve the speed of interpretation by 10 fold since pilots could very quickly eliminate notices that don’t affect them. You could almost scan down by the patterns alone and get to those you care about.

4. Only use abbreviations that are known by 90% of the pilots. That’s a relatively short list. While it may be ideal for all pilots to know all likely abbreviations, that is not the reality. I’ve had numerous times when neither I nor my first officer knew what an abbreviation meant. In nearly every case a call to the dispatcher revealed he didn’t know what it meant either! Some of them I knew back in various training stages or college, but years of filling my brain with more commonly appearing material has faded those memories. 

Lets Do What We Can

These are all things that could be done relatively cheaply, even on a per-life-saved basis. My hope is to encourage those who are in a position to enact change. We’ve done so much already, lets keep going. Lets at least do the easy stuff to continue making our operation the safest it can be.

Please send questions or comments to:

Thanks for listening.

Jeff Goin
Captain, 737