Signal Charlie

Dedicated to the continuous improvement of aerospace safety

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Fly Like the Pros

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With immense respect to Dr James Reason, it’s not slices of cheese out there, It’s all one cheese fondue. Hard to pick one piece out from the other. Professional pilots fly to and above regulated standards to avoid being covered in that cheese, and those standards provide both a challenge and an opportunity for all members of the aerospace team to strive for and exceed.

If you are flying Part 91, take time to sit down with a 135 pilot. 135? Seek out a cohort from the 121 world. And don’t miss out on opportunities to benchmark and compare best practices with our military aviation folks. All that said, some of the most impressive pilots I have ever flown with were working their craft in the Part 91 world, I have learned a lot from them.

Lifelong learners seek out knowledge from subject matter experts, it’s time to develop Professional Pilot Standards that include leadership training and improve our exchange of knowledge. It’s a vast expanse of sky and space out there, but we all share it.

Fly Smart


Please stay tuned while we get our site back up to speed, especially our Pages on SMS, Human Factors, Knowledge Exchange and Leadership.


-Advanced Aircrew Academy – Training to meet part 135 and IS-BAO requirements: Advanced Aircrew Academy

-FAA Safety Team Wings Program – Pilot and AMT Proficiency Program Courses: FAASafetyTeam WIngs

-Human Factors Analysis and Classification System (HFACS) – systematically identify active and latent failures within an organization that culminated in an accident: HFACS

-Human Factors Associates – Diagnostic assessment of a client organization’s safety effectiveness regarding high-reliability performance and intervention strategies: HFA

– International Society of Safety Professionals – Offers certification for International Safety Managers: ISSP

-King Schools – Offers a plethora of choices, some of which are free and offer Wings Pilot Proficiency Program credit, and could get you a discount with your insurance provider: King Schools

Written by Clark

May 26, 2022 at 10:08 pm

Posted in Uncategorized

Runway Safety & Communications 101

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“WestJet plane in near-miss at L.A. airport

WestJet Boeing 737 came within 15 metres of colliding with a Northwest Airlines Airbus A320 that was taking off

LOS ANGELES (AP) – A WestJet airliner on a flight from Calgary was involved in a near-miss Thursday with another jet on the tarmac at Los Angeles International Airport, aviation officials said.

The close call happened at about 1 p.m. and appeared to have been the result of mistakes made by both the arriving pilot and a ground traffic controller, said Ian Gregor, a spokesman for the U.S. Federal Aviation Administration.

Officials said the WestJet Boeing 737, which seats up to 132 passengers, came within 15 metres of colliding with a 150-seat Northwest Airlines Airbus A320 that was taking off.

The Northwest jet was travelling about 240 kilometres an hour when the WestJet plane approached its path. The WestJet plane managed to stop just in time to avoid a crash.

No one was hurt, authorities said. An investigation was under way.

Gregor said the arriving pilot switched radio frequencies too early after landing and was unable to receive final directions from the air traffic controller, the Los Angeles Times reported on its web site.

When the WestJet pilot notified the ground traffic controller that the plane was proceeding to its gate, the ground controller cleared him without checking first with the air traffic controller.

Aircraft arriving at the Los Angeles airport must cross the inside runway to reach their gate.

The “runway incursion” was the eighth such incident at LAX this year, matching the total for all of 2006.”

Communications are key for safe operations on the ground. Keep aware of active runways during taxi and assess incursion potential.

Fly Smart


Written by Clark

August 31, 2007 at 6:02 pm

Flying Safety for Dummies

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Don’t go flying if the birds are walking.

Try sailing.

If there’s no wind, row. Or head to the airport.


Written by Clark

April 6, 2007 at 10:24 pm

Posted in Uncategorized


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Written by Clark

March 13, 2007 at 5:28 pm

Posted in Uncategorized

Hello world!

with one comment

Welcome to This is your first post. Edit or delete it and start blogging!

Written by Clark

March 11, 2007 at 7:34 pm

Posted in Uncategorized

Safety Management System

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High Flight

Oh! I have slipped the surly bonds of Earth
And danced the skies on laughter-silvered wings;
Sunward I’ve climbed, and joined the tumbling mirth
Of sun-split clouds, — and done a hundred things
You have not dreamed of — wheeled and soared and swung
High in the sunlit silence. Hov’ring there,
I’ve chased the shouting wind along, and flung
My eager craft through footless halls of air. . . .

Up, up the long, delirious burning blue
I’ve topped the wind-swept heights with easy grace
Where never lark, or ever eagle flew —
And, while with silent, lifting mind I’ve trod
The high untrespassed sanctity of space,
Put out my hand, and touched the face of God.

— John Gillespie Magee, Jr

Aviation System Safety
by Kent Lewis

An aviator’s job is to make up for the inefficiencies of the aviation system. Our system is a composite of personnel, equipment, materials, facilities, procedures, regulations, software, etc…Compliance with regulations and procedures alone is not enough to prevent mishaps.

“The application of a “Systems Approach” entails identifying all of the major components of a system and attempting to understand the potential influence that various system components have (individually and collectively) on overall system performance.” (Naval Postgraduate School Aviation Psychology Lecture Summaries, 1992, p.19)

The System Safety “life cycle” concept is an export from System Safety Engineering. Applying the same principles to operational aviation safety minimizes risk by continually improving the operational safety process. The keys to this process are communication and integrity of the feedback loop.

We need structure and tools for systematic improvement, and the models below are tools to be utilized as basic system safety checklists . The 5 Step model below is utilized by DoD, the 3P Model is emerging from the FAA/Industry Training Standards (FITS) program and the Attitude Model is developed from the fundamental skills of Attitude Instrument Flying. Susan Parsons of the FAA wrote an excellent article comparing the 3P model to attitude flying. (FAA aviation News, 2005, p.1) I have gone a step further to compare all 3 checklists below. “Clark” Kent’s Triple A model, listed at the end, was developed by the author while creating this text and is excellent for rapid planning.

These checklists are flexible in scope and applicable to every segment of a Software, Hardware, Environment, Liveware (SHEL) model. Another model is Man, Machine, Mission, and Medium. Liveware, or Man, is the most important component of any system, because you initiate or conduct most of the model checklists and activities. These checklists can be used to plan some weekend VFR flying, evaluate emerging technology or change operational procedures at a major airline. One way to look at it, you are conducting an accident investigation before a human or material factors cause a failure of your safety program. Mishaps are seldom the result of single causes, but typically represent hazard events occurring in a single system. This proactive investigation will help you identify and eliminate all hazards before they turn into the causal factors of a mishap.


Clark Kent’s model is simple: Ask – Assess – Act (Triple A)

I believe that the next step for the aviation industry is to apply the system safety process to… the system safety process, with a focus on leadership, human factors and standardization of operational procedures. Collaboration amongst all sectors of the aviation industry to establish a list of tactical issues and strategic priorities would be a good start. As a parting thought, remember…..

Attitude + Power (Knowledge) = Performance

This equation flies your aircraft, it will also optimize your aviation skills. Your professional attitude plus a desire to never stop learning help you make the leap from pilot to AVIATOR, or apprentice to craftsman.

Preflight yourself before you go…use the 3P Personal Minimums Checklist developed by Uncle Sam…and realize some return on your tax dollars…

PAVE Checklist

Fly Smart
Clark 🙂
Contact info:

Written by Clark

March 11, 2007 at 6:28 pm

Posted in Uncategorized

Aviation Leadership

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Aviation Leadership Principles and Traits

by Kent B. Lewis
(shamelessly adapted from the U. S. Marine Corps)

Aviation Leadership Principles

  • Know yourself and seek self-improvement.
  • Be technically and operationally proficient.
  • Develop a sense of responsibility among your team mates (FSS, ATC, maintenance, crew, FSDO, AOPA, EAA).
  • Make sound and timely decisions.
  • Set the example.
  • Know your team and look out for their welfare.
  • Keep your team informed.
  • Seek responsibility and take responsibility for your actions.
  • Ensure assigned tasks are understood, supervised, and accomplished.
  • Train as a team.
  • Employ your command in accordance with its capabilities.

Aviation Leadership Traits
• Dependability
The certainty of proper performance of all duties.
• Bearing
Creating a favorable impression in carriage, appearance and personal conduct at all times.
• Courage
The mental and physical quality that recognizes fear of danger or criticism, but enables one to proceed (or not proceed) in the face of it with calmness and firmness.
• Decisiveness
Ability to make decisions promptly and to announce them in clear, forceful manner.
• Endurance
The mental and physical stamina measured by the ability to withstand pain, fatigue, stress and hardship.
• Enthusiasm
The display of sincere interest and exuberance in the performance of duties.
• Initiative
Taking action in the absence of orders or regulations.
• Integrity
Uprightness of character and soundness of moral principles; includes the qualities of truthfulness and honesty.
• Judgment
The ability to weigh facts and possible solutions on which to base sound decisions.
• Justice
Giving reward and punishment according to merits of the case in question. The ability to administer a system of rewards and punishments impartially and consistently.
• Knowledge
Understanding of a science or an art. The range of one’s information, including professional knowledge and an understanding of your craft.
• Loyalty
The quality of faithfulness to country, to one’s passengers and team.
• Tact
The ability to deal with others without creating offense.
• Unselfishness
Avoidance of providing for one’s own comfort and personal advancement at the expense of others.

For a fun time, compare these USMC principles with W. E. Deming’s 14 STEPS TO TOTAL QUALITY MANAGEMENT

    1. Create constancy of purpose for improvement of product and service.
    2. Adopt the new philosophy.
    3. Cease dependence on mass inspection.
    4. End the practice of awarding business on price tag alone.
    5. Improve constantly and forever the system of product and service.
    6. Institute training and retraining.
    7. Institute leadership.
    8. Drive out fear.
    9. Break down barriers between staff areas.
    10. Eliminate slogans, exhortations, and targets for the workforce.
    11. Eliminate numerical quotas.
    12. Remove barriers to pride of workmanship.
    13. Institute a vigorous program of education and retraining.
    14. Take action to accomplish the transformation.

or consider Stephen Covey’s 7 habits of Highly Effective People

1. Be proactive: Principles of Personal Vision
2. Begin with the end in mind
3. Put first things first: Principles of Personal Management
4. Think win/win: Principles of Interpersonal Leadership
5. Seek first to understand, then to be understood
6. Synergize Principles of Creative Communication
7. Sharpen the Saw: Principles of Balanced Self-Renewal
and this just in, the 8th habit..
8. From effectiveness to greatness

Contact info:

Written by Clark

March 11, 2007 at 4:44 pm

Posted in Uncategorized

Human Factors

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Human Performance

by Kent B. Lewis

Human Performance in aviation is the study of pilot, crew, mechanic and controller performance and health issues. Performance in any system is affected by human factor issues such as design of flight decks, physiological and psychological variations, and the interaction and communication between all participants.

Human Factors

“A broad field that studies the interaction between people and machines for the purpose of improving performance and reducing errors. As aircraft become more reliable and less prone to mechanical failure, the percentage of accidents related to human factors increased. Some aspect of human factors now accounts for over 80 percent of all accidents. Pilots who have a good understanding of human factors are better equipped to plan and execute a safe and uneventful flight.” (FAA Instrument Flying Handbook, 2001, p. 1-1)

Within human factors, specializations develop that use an interdisciplinary approach to the scientific study of the complex human-machine system. Examples of these specializations are aeromedical, critical incident response, first responder stress debrief, professional standards and pilot assistance.

  • Human factor elements include:
  • Design/System Failure
  • Organizational
  • Supervisory
  • Medical/Physiological/Psychological
  • Communications
  • Crew Resource Management
  • Aeronautical Decision Making
  • Attitude/Personality
  • Knowledge or Skill
  • Sensory-Perceptual

Mishaps: “WHO” did “WHAT?”

“The Naval Safety Center periodically publishes a list of the most common aircrew errors, shown below:

  • Inadequate crew coordination
  • Procedural violation
  • Physical or mental condition
  • Misuse of flight controls
  • Inadequate flying speed
  • Poor flight preparation
  • Inadequate lookout procedure

While the above designations are good descriptors concerning human error mishaps, they do not tell us much about the “Whys”. From a human factors standpoint, we need to relate the occurrence of mishaps to the behavior of people in the performance of their jobs. Accomplishing this may may be possible if we can more accurately define human factor “causes” of accidents, and through an understanding of the capabilities and limitations of human performance, develop improved mishap prevention measures.” (Naval Postgraduate School Aviation Psychology Lecture Summaries, 1992, p.3)

These same type of errors may result in injury to factory workers, poor performance of surgical teams or inefficient business management. Development of intervention strategies to combat poor performance and optimize system capabilities are key to everyone’s bottom line. To do this, we must identify “Why” and target the most appropriate levels for intervention.

DoD and the FAA are currently collaborating on defining human factor causes with the development of a Human Factors Analysis and Classification System (HFACS). Traditional intervention strategies focus on prevention of specific types of accidents, such as Controlled Flight Into Terrain (CFIT) or Stall/Spin mishaps rather than human error. Corrective recommendations have been focused on decision-making vs a wide range of possible human error categories. Causal factors must be analyzed and classified to accurately capture and recreate the complex layers of human error in context with the individual, environment and mishap or event. The resulting taxonomy will address latent failures of the system and active failures of the operator, from the earliest opportunity for intervention to the last.

The DoD HFACS model currently addresses these basic layers of system failure:

Organizational influences

  • Resource/Acquisition management
  • Organizational climate
  • Organizational process


  • Inadequate supervision
  • Planned inappropriate operations
  • Failure to correct known problem
  • Supervisory violations

Preconditions to Acts

  • Environmental factors
  • Physical
  • Technological
  • Condition of individuals
  • Cognitive factors
  • Psycho-behavioral factors
  • Adverse physiological states
  • Physical/mental limitations
  • Perceptual factors
  • Personnel factors
  • Coordination/communication/planning factors
  • Self-imposed stress


  • Errors
  • Skill-based
  • Judgement and Decision -making errors
  • Misperception errors
  • Violations

A Human Factors Intervention Matrix (HFIX) is being developed to pit Unsafe Acts against Intervention approaches, as a useful tool to evaluate safety programs. As part of the FAA’s Safer Skies initiative, Joint Safety Analysis Teams and Joint Safety Intervention Teams studied civil aviation accidents associated with:

    -Controlled Flight Into Terrain (CFIT)
    -Approach and Landing
    -Loss of Control
    -Runway Incursions
    -Pilot decision-making

The results were classified based on NTSB recommendations for corrective action. The results found that that NTSB recommendations routinely targeted Organizational/Administrative levels (36%) and Technological/engineering approaches. “However, unlike the NTSB where relatively few recommendations targeted the human, nearly 1/3 of those obtained from JSAT/JSATs did so.” (Developing a Methodology for Assessing Safety Programs Targeting Human Error in Aviation, 2004, p. 4) Analysis suggests that additional interventions should be directed towards skill based errors, violations and modification of the task and environment.

In the majority of cases, a mishap “happens” before the aircraft has ever left the ground, at times as high as the organizational or supervisory level. Mishaps are caused by hazards with human and material factor roots. Identification of hazards through the use of system based safety programs and risk management methodologies will result in interventions at the earliest and most appropriate levels. The earlier that a hazard is identified, the earlier it can be assessed, eliminated or controlled.

Safety Quote
“You can’t go on liberty if you’re dead”.
Lt Col Michael Kurth, HMLA-369
Navy Cross recipient
Desert Storm

Preflight yourself before you go….Know your personal limitations. Use the PAVE checklist.

Another NASA, DoD and FAA initiative is the National Plan for Civil Aviation Human Factors

Two goals:
1. Reducing error in human-system interactions
2. Increase efficiency of human-system performance

The national agenda focuses on 2 major elements
1. Human-centered automation
2. Selection and training
3. Human performance assessment
4. Information management and display
5. Bioaeronautics

-Application of research:
1. Create environment for change
2. Develop HF education and training programs at all levels
3. Equip personnel and facilities with modern tools and techniques of the HF engineering discipline.
4. Develop infrastructure to translate and disseminate human factors products.

Contact info:

Written by Clark

March 11, 2007 at 4:44 pm

Posted in Uncategorized


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About Signal Charlie
Signal Charlie is an aggregate site being developed to promote safety in high reliability organizations, with a focus on aviation.
When trying to decide on a name for the site, I remembered my Naval Aviator days and the codewords from the carrier, “Signal Charlie”, which meant that the flight deck was ready for landing ops. This was always a welcome message, especially after a long flight. What you didn’t want to hear was “Signal Delta”, which meant take up a holding pattern on the starboard side of the ship. You could always get a green deck, though, by telling the Air Boss that you had “pony” (mail) on board. Signal Charlie will be a site that advances the goal of smart flight operations in dynamic environments, and we hope this site generates a lot of “pony”.

The Charlie signal flag also means “Affirmative”, and this represents the proactive nature of a quality Safety Management System (SMS), the future of aviation safety. SMS components include an open reporting culture, risk management methodology and continuous improvement process. In SMS, people nurture partnerships that promote operational goals and safety. Positive communications fuel these partnerships, and Signal Charlie is meant to be a vehicle for critical team communications.

Our site will be used to communicate ideas on an international deck, developing the same kinds of standardization that the International Code of Signals offers. Well developed, standardized procedures and efficient communication are key components of any quality system.

Please be patient as we add content to this site, and feel free to post your comments and recommendations.

Fly Smart
“Clark and Tokenchick”

About “Clark” Kent Lewis

Aviation Safety Programs
Kent Graduated from the U.S. Navy Postgraduate School’s Aviation Safety Officer course, and was the Director of Safety and Standardization at MCAS Yuma, the largest aviation training facility in the United States. He was previously the Safety Department Head at VT-27, the Navy’s busiest aviation training squadron. His safety programs have been recognized as the best in the Navy/Marine Corps and have a zero mishap rate.

Kent volunteers as a FAA Safety Team Lead Representative for the Ft Worth FSDO, has attended the ALPA Basic Safety School, Safety Two School, Advanced Accident Investigation course and is the DALPA Atlanta Council 44 Safety Chairman. His focus is Human Factors and System Safety , and he is a member of ISASI.

Flight Instruction
Kent was a flight instructor while in the U.S. Marine Corps, teaching Navy and Marine primary and intermediate students in the T-34C, a fixed wing turboprop trainer. He is a graduate of the Naval Air Training Command Flight Instructor Training Course. He also flew helicopters and was a Terrain Flight, Search And Rescue and Night Vision Goggle Instructor. He recently gained certification with the FAA to be a Certificated Flight Instructor, Instrument Instructor and Multi-engine Instructor in airplanes. His flight instructor training was conducted at Cliff Hyde Flying Services, Ellington Field (KEFD), Houston, TX. This Part 141 program was part of the San Jacinto College Aeronautical Technology curriculum.

Kent is a graduate of the University of Texas at Austin, with a Bachelor of Arts degree in History, and he has a Masters degree in Library and Information Science from Texas Woman’s University.

I am a history major. I believe that the past is prologue. The archives bear that out. Most major aircraft accidents are not acts of God. In our recommendations we try to take what we have learned and correct situations so it shouldn’t happen again.”
— James Hall, NTSB, 1996.

Commercial Pilot
Kent is certified by the FAA as a multi-engine Airline Transport Pilot, and as a Commercial Pilot for single-engine airplanes and Helicopters. He has over 20 years of flying experience, for the U. S. Marine Corps, American Eagle Airlines, and Delta Air Lines.

Emergency Preparedness and Response
Kent is a graduate of the National Search And Rescue School’s Inland SAR Coordination course, and was the SAR Officer for MCAS Yuma, AZ. His SAR Coordinator responsibilities included Interagency coordination with over 50 Local, State, and Federal Response Agencies. He has over 20 years experience with the Incident Command System and authored the Incident Action Plan for MCAS Yuma, the Nation’s largest joint use airfield.

Thanks for visiting the site!


Contact info:

About Audrey aka “Tokenchick”


Audrey graduated with honors from Corpus Christi State University, receiving her Bachelor of Arts in Communications while majoring in Drama. She graduated Texas Woman’s University with a Masters in Drama with an emphasis on Costume Design. She is an expert in interpersonal, small group communications, the key component to efficient and safe teamwork. Whether you are in the cockpit, classroom or boardroom, if you can’t communicate, you can’t succeed.


Audrey has also been designing, drafting and constructing costumes for over 30 years. She is also an accomplished actor, having appeared on stage, television and film productions.

Small Business Owner
Audrey is the sole proprietor of

Contact info:

About Spooky

Spooky is one of the smartest people I know, working on a Masters of Science in Aerospace Engineering and incredibly talented. Spooky graciously volunteers time to mentor me on the intricacies of website design and things that involve tremendous amounts of calculus.

Contact info:

Written by Clark

March 11, 2007 at 3:56 pm

Posted in Uncategorized