Vol. XXV, No.

MISSION SAFETY INTERNATIONAL

Safety Net

July, 2015

MFS Ministry in Zambia

by Jon Egeler

he country of Zambia sits in the center of south

central Africa, and is one of the more developed
countries of Africa. Once a British colony, English is its
official language. Despite great development, people still
face challenges in getting around, especially in the far
north western regions.
This is where Mission Flight Services (MFS) comes
in. MFS is based at Kalene Mission, Zambia, close to the
borders of Zambia, Democratic Republic of Congo, and
Angola. The roads to Kalene from Lusaka, capital of
Zambia, are not in the best of shape, and the journey is a
day-long marathon that can be quite rough and grueling.
Continued on Page 2

Inside

Congo
Calling
pg. 3

Do Audits
Work?
pg. 5

UIM Hangar
Door Save
pg. 5

Medical Wings
in Gabon

MSI Top Ten

No. 4

MSI Safety
Summit

pg. 6

pg. 7

pg. 8

MFS Ministry in Zambia, contd.

MFS began in 1993 as CMML Flight Services, a vision by Bruce

Poideven to serve the Kalene hospital, CMML missionaries there and
in the surrounding area, and Sakeji School with air transportation
that would save people countless travel hours and wear and tear on
their vehicles and bodies.
Today, 22 years later, MFS operates a Cessna 207 and a Cessna
182 from their beautiful hangar in Kalene. In addition, they have
set up a small retreat center in Kalene, where people can come for a
break from their ministries, or host guests visiting from afar.
They also operate a guest house in Lusaka. This set-up works
quite well, as visitors (such as the MSI team) flying to Lusaka on
one of the international airline flights can stay in the guest house
overnight while they recuperate from their journey. Others can go to
Lusaka for a few days of shopping, medical appointments or visits to
government offices and have a safe place to stay that provides meals,
internet access, and clean and comfortable beds.
The MSI team consisting of Jon Egeler and Clay and Joy
Norman enjoyed a brief stay in the Lusaka guest house before Bruce
Poideven picked us up and took us to the airport to fly in the 207
up to Kalene. Following our flight (just over 2.5 hours), the 207
was opened up for one of the maintenance inspection phases. The
maintenance specialist, Drew Taylor, found a crack in the right rear
doorpost which needed to be repaired before further flight.

This wrinkle put added stress on the MFS team during

the audit, as they worked to source parts and information, and
scrambled to arrange our transportation to Ndola at the end of the
week for our next audit with UMAM. The MFS team handled the
situation with grace and professionalism. Drew was able to make the
necessary repairs, but not before we flew with Bruce to Ndola in the
182. Thus the wisdom of having a second plane was demonstrated,
and everything worked out well. It was also a good opportunity for
MSI to see them in action in real-life situations.

This was the second audit MSI conducted for MFS, and much
progress has been made since our last visit. The aircraft have been
refurbished, equipment improved, and facilities upgraded. We
anticipate that MFS will continue to play a vital role in serving Kalene
and the surrounding area in the years ahead, and will continue to do
so in a safe, professional manner. It was a joy to work with them, and
we look forward to our next visit.

All Pictures in this article

by Clay Norman

MSI

Congo Calling

by Jon Egeler

f you were to ask most people who are familiar with Africa about
the Democratic Republic of Congo (DRC), they might talk about
tremendous potential, very poor or non-existent infrastructure,
rampant corruption, an ineffective central government, and years
of internal conflict and warfare. They wouldnt be far off the mark.
Even in the mineral-rich south eastern Katanga region
of DRC, many years of corruption and conflict have hindered
infrastructure development. The few existing roads often are not
passable, and the countrys post office has not been functional for
decades. The result is that much business and travel depend on
aircraft. The work of the church in DRC is no exception.
The Methodist church has been active in DRC for well over
100 years, and several different flight programs
have been used by them for many years. The
current programs are an outgrowth of these past
ministries, and still retain some of the original
names: Southern Congo Wings of the Morning;
Wings of the Morning North Katanga; and
Wings of Caring.
While each of these programs currently
operate under individual regional leadership,
there has been a recent effort to form an Aviation
Board that will oversee all of them, to allow greater
cooperation, sharing of resources, and greater
effectiveness. This has led to the name United
Methodist Aviation Ministries (UMAM).
The MSI audit team of Jon Egeler and Clay
and Joy Norman went to DRC to conduct the
second audit of the UMAM programs in April.
This trip presented several unique challenges.
The obvious one is that UMAM represents three
separate programseach with one aircraft
that cooperate and operate under the same
Operations Manual and have as their common
coordinator veteran mission pilot Steve Quigg.

The second set of challenges was trying to get everyone

together for the audit, with some pilots in the USA for meetings,
and one maintenance specialist in South Africa with their Cessna
Grand Caravanwhich was in Pretoria at the time of the audit.
UMAM uses three maintenance facilities in South Africa for
more specialized work on the Caravan. As a result, MSI flexed its
normal methods, and conducted the interviews in various places
including some ahead of time in the USand also by Skype.
Jon went to South Africa to interview the UMAM maintenance
specialist family, inspect the Caravan and see the maintenance
facilities used in South Africa. Then the team met up in Zambia
and headed by road to Lubumbashi, capital of DRC,.

Continued on Page 4

Congo Calling, contd.

Lubumbashi has grown and developed quite a bit
since we were there in 2012. Its obvious that there is a
great deal of wealth around, from the recently paved
streets clogged with way too many cars to handle,
modern shops, numerous restaurants, and many people
carrying the latest smart phones. Just to remind us that
we were still in DRC, the post office building has been
converted into office space, and no one, not even the
nicer restaurants, seemed to want to accept credit cards.

Once one travels outside the city, though,

signs of that wealth disappear quickly. One of
the big ministries that UMAM is involved with
is providing medical flights to people so they can
get adequate medical care. The Caravan that was
recently acquired has been a real blessingas well
as rather expensivefor these flights and the local
church is working to develop a medical insurance
program to keep the medical flights going.
There are great challenges ahead. More
unity and cooperation between the programs will
require increased trust and cooperation on the part
of local leadership. Major elections are coming up,
both for the country of DRC, and for the church
leadership, many of whom are retiring. The church
wants to open a new flight program and personnel
and equipment needs to be acquired for that. Avgas
is still very hard to come by, requiring critical
decision making.

Amidst these challenges, God is using UMAM to bless many

people in Southern Congo, and the future looks bright as they
seek to follow His leading.

All Pictures in this article

by Clay Norman

MSI

Do Audits Work?
by Jon Egeler

that are the same as in missionary aviation.

e are often asked if Safety Audits really help. Isnt it easy for
organizations to put on a good front and fool the auditors?
The answer is yes, it is possible to make things look better than they
are, but audits still work. MSI has been traveling all over the globe
conducting Safety Audits for the past 32 years and we have noticed
some changes in missionary aviation. Audits have been especially
emphasized in the past 8 years or so, and some of these changes are
quite dramatic. Here is some of the progress we have noted:

Raising the bar

Aircraft condition and maintenanceoverall, aircraft are
being maintained to higher standards. Most mission aircraft
look good.
Equipmentboth the quality and condition of the equipment used to maintain the aircraft has improved. More and
more, the right tools are being used, even in very remote locations.
Facilitiesalong with the equipment, facilities have been
upgraded to higher standards, and now meet the requirements
more fully.
Occupational Health and Safetymuch progress in ensuring the safety of the people working around the hangar has
been seen.
Airstripsyes, airstrips have been improved a lot. There
is plenty still to be done, but there have been many improvements.
Moving toward less serious accidentsas you may have noticed, fatalities are way down from where they used to be. Most
of the accidents involve runway excursions at low speed, not
the loss of control or crashes on go-arounds that we used to see.

Changing attitudes
Professionalismwe have seen a significant shift in attitude
toward being and acting like a professional, and away from the
image of the pilot showing up in a dirty t-shirt and shorts.
Striving for excellencea personal emphasis on doing
things right, striving to do it to the best of ones abilities.
Genuine desire to see things done bettergoes along with
striving for excellence, but acknowledging that there is room
for continuous improvement in ones ministry.
Above reproachmaking sure all involved are not only
complying with the law, but are avoiding any appearance of disobedience.
Not flying under the radarestablishing good relationships with the governing authorities rather than trying to not
be noticed and left alone.
Beginning to welcome accountabilityasking for input and
evaluation.
Open to suggestions/input from the industryno longer
thinking that the rest of aviation (airline, military, corporate)
is so different that they couldnt possibly have anything to offer,
but recognizing that there are many similarities with principles

We have been aware of the role audits have played in all these
improvements over the years and know that each of these areas has
been a point of emphasis during our audits. We are very pleased to
see the progress missions have made over the years.
While we all know there is still improvement to be made,
KEEP UP THE GOOD WORK!

MSI

UIM Aviation Hangar Door Save

by Kevin Dunn

ecently we had the opportunity to see a very real life example of

the benefit of having an MSI Safety audit. Yes, audits cost time
and money, but there is significant payback in both. . .
During our audit in 2007, one of MSIs recommendations was
to change the operating switch on our 40 bi-fold hangar door. The
door was wired so that if either the up or down switch was pushed,
the door would automatically open or close on its own. MSIs recommendation was that we rewire the down switch so that someone
had to continually hold the switch to make the door close. The reasoning was that if something unexpected came under the door, no
one had to make a run for the switch to stop the door. So we made
the change, and quite frankly, it is a pain. Now, to close the door,
someone has to stand there and hold the switch the whole time
while the door is in transit.
Well, you can probably see where I am going with this.

During a recent hangar shuffle, we moved a core engine that

was on a palletheaded back to Lycomingout of the way to get an
airplane out. Once we restacked the hangar, two of us checked the
door for clearance on the aircraft, forgot about the engine, called for
door closure and went back to work.
The crunching noise was the first indication that something
was wrong. Fortunately, the core engine had its crate packing material lying on top of it and as the door came down, thats what it
hit first. The noise alerted a nearby mechanic, whose yell startled
the guy at the controls. His reaction was to jerk his hand off the
switch and the door stopped instantly. The result was the saving of
one very expensive engine and a hangar door which lived to work
another day.
One bad incident avoided and we more than made up for the
cost of the audit. Wow, did the system ever work!

MSI

Medical Wings in Gabon

by Jon Egeler

guest house was running pretty well under some local leadership,
so the move was a good fit for the program.
MSI conducted its second audit for AMB in September last
year. The audit team consisted of Jon Egeler and Jim and Diana
Brownlee. Rob met us in Libreville and flew us out to Bongolo in
the AMB Cessna 207. Rob and Bintou were wonderful hosts as we
interviewed, poked, prodded, and dug into the operation. What
we found was a well-run small operation that is serving the needs
of the hospital and missionaries quite well. Rob also helps keep
the internet connection going, which keeps everyone happy and
well-informed. In appreciation and cooperation, the hospital has
contributed to the ministry by procuring fuel for the program, and
providing housing and a vehicle.
Bongolo hospital was started in 1977 by Christian and Missionary Alliance missionaries to serve the people in rural Gabon. It
has grown to be one of the largest and well-respected regional hospitals in the country. Their top-notch eye hospital draws patients
from all over the whole country. Their active volunteer doctor program, and a training program for surgeons brings doctors from all
over Africa. The eye hospital and the visiting doctor programs are
especially dependent on the aircraft to provide transportation.

viation Medicale de Bongolo (AMB) is a ministry started

in Gabon by Steve Straw in 2009. In November 2009, MSI did
its first audit for what was then called Air Calvary in Libreville,
even before the aircraft had arrived in Gabon. Some have asked
how we could do a Safety Audit before flight operations had even
commenced, but it was actually very valuable for us to be able to
go over the plans Steve had, and give suggestions and input. So our
relationship with AMB goes back to the very beginning.

AMB flies a Cessna 207, primarily between

the hospital at Bongolo and Libreville, the capital
city of Gabon. Most of the passengers are hospital
staff, workers, or volunteers, with some patients occasionally. Since Bongolo is a hard day-long drive
over rough roads (when they are passable) being
able to fly the trip in just over 2 hours is quite a
blessing. This is especially true when transporting
delicate medical equipment or patients with eye or
brain trauma.
Originally, Steve Straw and his family started up the flight program in Libreville and operated the mission guest house there. This kept them
based in Libreville and very busy. As the family
grew up and the childrens educational needs
changed, the Straws moved to Cameroon, and
Rob and Bintou Peterson came on loan from SIL/
JAARS in Cameroon to continue the flight program in Gabon.
Rob had been flying for SIL for a number of years, and Bintou
was a trained doctor, so moving the base from Libreville to Bongolo
made a lot of sense. There already was a hangar at Bongolo, and the

We appreciate you, supporters of MSI, for the indirect part

you play in ministering to people in Gabon through MSI to Avation Medicale de Bongolo.

Inset Sign and Hospital Pictures by Jim Brownlee.

Other Pictures in this article by Jon Egeler

MSI

MSI Top Safety Concern No. 4

Unstable approaches

Clay Norman Picture

300 feet. In these cases, the aircraft must be stabilized even earlier
in the approach, when going around is still an option.
The absolute key to the whole concept is that if all of the stated parameters are not in place by the pre-determined point, a goaround is done.
Despite the great success of the stable approach policy, airlines continue to have approach and landing accidents, although
much fewer than before. Most of them are a result of an unstable
approach, so why are pilots not going around when they are supposed to?
The answer to that is a bit complicated, but quite insightful
for missionary aviation. There are a number of factors that work
against a pilot going around:
Pride/embarrassmentpilots dont like to fail, and a
botched approach feels like failure. Additionally, others are
watching, and they dont like to look bad by having to do it over.
ATC/trafficin a controlled environment, or when
there are others that will be affected by the go-around, it is
very hard to make oneself become a nuisance or problem for
them, which often happens with a go-around.
Unaware of instabilityquite often during an accident
investigation, the pilot reported that it was a normal approach,
but the flight data recorder says otherwise. It is easy to get tunnel vision when you are concentrating hard, and miss clues
that indicate things are not going well. Overcoming this is one
advantage of multi crew.
I can salvage it/ Its not so badquite often pilots have
been trained and rewarded for pulling off a good landing even
when the approach was pretty ugly. We tend to be optimists,
and pretty confident in our abilities, which can be a dangerous
combination.
Thought process of predisposition to landingpilots
are conditioned to expect every approach will end with a landingit is what is carved into our consciousness through repetition and practice. Somehow we have to shift our thinking
from we are going to land now, no matter what to unless
things are looking good, we will be going around.

ver 20 years ago, airlines were very concerned about the high
number of approach and landing accidents occurring. The
Flight Safety Foundation, a non-profit safety consulting organization that works primarily with the airlines, formed a task force
to examine the problem, and come up with some solutions. This
Approach and Landing Accident Reduction (ALAR) task force developed a report and tool kit to help airlines eliminate this type
of accident. Their efforts were very successful, and these types of
accidents dropped to nearly one tenth of what they had been.
Fast forward to today, and missionary aviation is in much the
same situation that the airlines were in 20+ years ago. Nearly 66% of
our accidents fall into the approach and landing category, just like
the airlines did. What did they do that we might be able to duplicate?
One of the primary focuses of the ALAR task force was on
stable approaches. This is simply defined as ensuring the aircraft
is in the right place and speed by a predetermined point in the approach, or a go-around is required. Now, that is an over-simplification, so here is a bit more detail.
The key essential parameters are:
Aircraft trackthe aircraft must be lined up with the runway or very nearly so.
Flight path anglethe descent (sink) rate and power setting should indicate a proper flight path approach angle (normally
close to 3).
Airspeedthe airspeed must be at the target airspeed.
Some additional criteria include having the aircraft configured properly for landing (gear and flaps, engine controls, checklists done), and any pre-flight briefings completed (additional crew,
passengers, flight following report).
For the airlines, the normal pre-determined point by which
all of the above criteria need to be met is 1000 feet AGL for instrument approaches and 500 feet AGL for visual approaches. For
many mission operators, it was found that for normal operations,
300 feet AGL for visual approaches works well.
In special cases, a go-around is not possible, or the approach
does not allow for the aircraft to be lined up with the runway by

Continued on next Page

MSI Top Safety Concern No. 4, contd.

What is so special about a stable approach? Can pilots not
handle several things at once? Yes, they can, and do, constantly. The
stable approach is simply a risk management strategy that seeks
to limit the variables in a very demanding and challenging environmentthe approach and landing. By minimizing the variables
when possible, the pilot is given greater ability to handle the unexpected, things like wind gusts, things on the runway, slippery or
soft surface, mechanical issues, etc. If the pilots bandwidth is taken
up dealing with an approach with lots of variables, he will likely
not be able to handle the unexpected, and chances of having an
accident go way up.
How do you implement a stable approach policy in your
organization or flying? Start by defining what makes a stable approach and give expected criteria. Set a policy that these criteria
must be met by the pre-determined pointthe approach gate
or a go-around must be accomplished. Make sure everyone knows
the policy. Train your pilots to use the policy, and practice it.
Practice is important. A go-around is a complicated and demanding maneuver that needs to be practiced to stay sharp and
proficient. In addition, terminating approaches with a go-around
needs to be practiced to break the habit patterns of the thought
process of pre-disposition to land. We recommend setting a policy
that at least one go-around a month must be done, which will keep
your pilots practicing the maneuver. Chances are, they will choose
to do their monthly go-around when they are not happy with an
approach, which is precisely the whole point.

It will also boil down to disciplinemaking yourself do it

even when you dont feel like it. Going around will need to be modeled by the experienced pilots when new pilots are observing.
How about cost? Wont it cost a lot to be doing all these goarounds? Actually, for the smaller aircraft that missions are operating, a go-around is very inexpensive. Yes, it will use some fuel and
time, but not that much, and the cost savings of avoiding even one
accident every ten years is huge.
Will it work? It sure has for the airlines, and it certainly will
for missionary aviation. Unlike what some think, there are a lot
fewer differences between airline operations and ours than it appears. Margins for error are small, and energy management is a big
deal in both types of operations. Whether it is a small plane landing on a short, slippery airstrip or a large heavy plane landing on
a longer slippery runway or with a tailwind, being high or fast will
have disastrous results. So could being low and slow. Regardless, if
we can eliminate up to 66% of our accidents, why wouldnt we try
it? We would be very remiss not to.
Some additional references: http://www.skybrary.aero/index.
php/Stabilised_Approach
So lets all take this issue of unstabilized approaches to heart
and work on it proactively. If we do, its my firm belief that well see
a significant reduction of mission accidents and thus continue to.

Make Safety a Way of Life!

Jon Egeler
President

MSI Announces Fourth Safety Summit

MSI announces that the fourth Safety Summit will be held November 3-5, 2015, at JAARS in Waxhaw, NC. In addition, some
special training will be offered by Larry Heintz on November 6th.
For the Summit, topics are being finalized, and may include:
SMShow is it working for you, and what help do you need?
Reporting systemssome ideas on how we all can
collaborate
Safety Officer trainingwhat needs to be done
Auditsstandards, internal and external, training to do them
Standards, particularly for audits, but also revisiting our
2005 Summit
Flight tracking and moving toward FOQA for missionary
aviation
Initial data collection and evidence preservation training
for field personnel
Key components of an ICAO Safety Management System

(according to the latest ICAO SMM)is this really
workable in mission aviation?

Mission Safety International, Inc.

328 E. Elk Avenue, Suite 1
Elizabethton, Tennessee 37643-3351
Telephone 423-542-8892 FAX 423-542-5464
E-mail [email protected] www.msisafety.org

What does MSI need to be focusing on moving into

the future?
Understanding the importance of hazard (non-event)
reportinghow can we better promote it?
Quality Management Systems vs Safety Management
Systemsdo we really need both?
Reactive, Proactive and Predictive sources of safety
informationwhat are these and how can we ensure
we are getting them?
MSI Top Ten Concerns and what we can do about them
You are encouraged to send two or more representatives
from your organization, perhaps a safety or quality person and
an operational one. We want a good discussion examining the
theory, but also keeping it practical.
If you have other topics to suggest, or are interested in giving a presentation on one of the above, let me know as soon as
possible at [email protected]
More information will be coming soon.

Safety Net is published periodically by Mission Safety International Inc., Harold W. Berk, Ed.
Articles appearing in this newsletter are the expression of the writer and edited as appropriate.
Every attempt is made to represent information and opinions accurately and fairly and in such
manner that an uninformed reader will not be drawn to erroneous conclusions. However,
there is no guarantee that these objectives will be fully realized.