The old adage, “more hurry – less speed” is true in many aspects of personal life but in aviation operations this sometimes results in tragedy. Often, this syndrome is accompanied in private operations by another well know aviation affliction called, “get home itis.”
How often have we seen pilots, engineers, air traffic controller and yes, even airport firemen hurry to the extent that they make critical safety errors? In our personal lives we sometimes look back and ponder why we put so much effort into saving seconds at the risk of endangering something more important. I find this question fascinating but it is a question for human factors experts.
The “hurry mode” (as I call it) and its dangers, are no more aptly demonstrated in the crash of an Ilyushin – 76 scheduled for a cargo flight from Khartoum in June 2008. The crew members were reported to be in a hurry and this observation is consistent with the evidence of poor checking, minimal use of checklists, a lack of awareness of the aircraft’s take-off weight, and reversing the aircraft from a tight parking bay rather than requesting push back assistance.
The “hurry mode” was further reinforced by the crew’s apparent use of an undocumented procedure of starting the take-off roll with the flaps retracted and extending them progressively in stages until reaching the required take off setting. Unfortunately, the crew forgot to set the take-off flap and slat setting before take-off resulting in the aircraft stalling at about 7 metres and subsequently pithing up and rolling to the left and crashing with no survivors.
The crew members were reported to be at the end of their tour and this was the last flight before returning home. Whilst I’m sure other safety cultural issues were at play, I wonder was this a case of “get home it is” and “hurry mode”? Each syndrome is dangerous but the combination is really serious.
My daughter arrives home and exclaims that I “butt dialed” her mobile telephone. “What”, I said. “Butt dialed me”, what I said. “You … butt dialed me” she said with some exasperation in her voice. I on the other hand, believed that I did not hear the phase correctly, and also with a degree of confused exasperation said, “What are you talking about?”
“Dad; you butt dialed me … I’m sure because I could hear you walking and buying things at the grocery store.” The light in my head was showing signs of a faint glimmer. I was starting to get the impression that I’d accidentally dialed her mobile telephone. “What is butt dialing?” I said. “You know, when you sit on your smart phone and you accidentally dial someone.” “Oh yes – err …. I knew that”, I said; not wanting to look like a complete Ignoramus Maximus!
A day or two later, daughter opened her mail and exclaimed, “Jessie’s 21 st Birthday party invitation and it’s a plus one”. I said “what”. “It’s a plus one invitation.” “What” I said. “A plus one Dad” she said. I won’t bore you with the details but I eventually discovered that a plus one is a party where you are invited to bring a partner!
These two exchanges reminded me about the importance of good communications for good safety. Communications is a two way street with a transmitter and a receiver. Both have to be tuned to the same wavelength just like a radio. If they are not; there is nothing but static.
I recently read of a runway incursion incident where the transmitter (the air traffic controller) and the receiver (the flight crew) were physically on the same frequency but not on the same wavelength. Apparently the crew was an infrequent visitor to the airport and the controller had his own adapted phraseology. The result was a mis-communication and the aircraft entered the active runway causing an aircraft on final approach to go around. Not unique and the lessons are old ones but still very relevant.
The lessons are obvious. Human error and safety are strongly influenced by communications. Like many human factors, an extra second more time to clearly articulate intentions and instructions and use standard phraseology, is not a costly investment but will pay handsome safety dividends.
The communication challenge is not unique to aviation; many businesses suffer from it – thankfully usually not with serious consequences. Aviation on the other hand is reliant on good communications and the consequences of a breakdown are often serious!
I’ve made an interesting personal conclusion about the general aviation industry in Australia.
It appears that small (micro) businesses employing up to five people and medium to large sized businesses employing 20 or more employees can be successful. Those small businesses with between 5 and 20 employees appear to struggle. I am informed that one significant problem is the cost of conformity with customer requirements and compliance with government regulations.
I have been often engaged to assist these businesses to ‘get out of trouble’, or to assist them in getting the better contracts or just to do something which will enable the owners to enjoy more than just wages.
Many aviation operators are required to establish certified Quality Assurance Systems, Workplace Health and Safety Systems (SMS), Environmental Systems and of course Safety Management Systems to enable them to compete for contracts with larger companies. These systems are a financial impost but, apparently, these days any business needs a larger contract to properly fund operations.
Whilst these systems all have some value, collectively, if one is not careful, they will not be used properly and fall into full or partial disuse until the next contract or scheduled audit. I assume that the intended consequence is to ultimately improve safety, but in many cases, the resource impost of maintaining these systems can be detrimental to safety. Some aviation tender requirements at best amount to a naïve and clumsy attempt to assess the safety potential of an aviation operator.
My observations confirm that some small businesses really end up with a number of disparate systems but one no system operating as it is intended. In my opinion, it may be prudent to operate a SMS properly or even combine it with a Workplace Health and Safety System (there are synergies), rather than have a number of disparate systems which might look impressive on a tender document, but cost lots of money and are quite ineffective in practice.
I’ll reserve my comments about the cost of regulatory compliance for another BLOG.
Larger companies and Government consumers of aviation services need to carefully consider the risks that they are trying to control and the safety outcome rather than select aviation businesses on the basis of an ill-considered and trendy wish list.
The melodrama plays out in our national capital – another aviation inquiry. This time its the Norfolk Island ditching. Lets hope that the inquiry gets to the root causes of this accident so as to prevent future aviation accidents of this nature. That said, I do not expect any radical change to the way the industry is regulated or the safety investigation regime.
A perusal of the Hansard makes for interesting reading but what is just as interesting, and even more so if you know the personalities and politics, are the supplementary submissions. Between ruffled feathers and guffs that need correction, there is quite a bit of emotional and physical energy being expended.
It would appear to me that as in any multi-party system the deficiencies are spread around and one would hope that this inquiry identifies real safety hot spots and sees them addressed.
In my view there are four key issues;
• The regulatory framework and oversight process
• The Company’s responsibilities
• The situations faced and subsequent decisions of the flight crew
• The rigour of the ATSB report.
On the last point; it’s been a long time since the ATSB has come under such scrutiny and in retrospect; the storm clouds had been building for years.
I am not going (and far be it for me) to pass judgement on any party, but rather ask the penultimate question. Prior to about 1990 (if my memory serves me correctly), Norfolk and Lord Howe and probably other remote islands required a mainland alternate regardless of the weather conditions.
What were the reasons for this requirement to be removed and what risk controls were supposed to address the obvious risk of the aerodrome becoming unavailable for a landing? Why weren’t these controls adopted?
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I believe that in so many ways aviation safety begins at breakfast. Regardless of whether you are an airport fireman, air traffic controller, maintenance engineer or pilot, I am convinced this is true.
Of course, I use the term “breakfast” metaphorically because some of us have had to work “back of the clock” and across time zones and, in these cases, any substantial meal will do.
As a young flying instructor, my Chief Fling Instructor drilled into me the importance of having a hearty breakfast which included a good dose of protein. Sorry, but I know that cereal will just not cut it when you have a big and sometimes stressful day ahead of you.
As I progressed through my career as a flight instructor and Examiner of Airmen, I found those students who performed poorly in flight training exercises or tests invariably had no or a light breakfast. Indeed, there was a short time during my flying career, that I forgot this important lesson and had the odd bad day myself!
A couple of years ago a tragic event prompted me to do my own research about the importance of protein on risk taking and decision making. The result of this informal research is that I’m more convinced than ever that safety really does begin at breakfast. I think that this important lesson should be taught and enforced during the flying training, and as a topic of Air Safety Regulators’ safety promotion and education activities, so that our safety sensitive people have sufficient and the proper grade of fuel to make sound decisions during their day.
I have just returned from Papua New Guinea and I’ve had a week of watching Air Crash Investigation on Nat Geo. I think I saw 6 episodes and enjoyed them all from a personal and professional perspective.
I had seen some episodes before but most were new to me. Almost all of the episodes examined a crash or series of crashes which were caused by an intentional breakdown of procedure caused by a breakdown in self discipline.
In one episode, a Boeing 757 eventually stalled and spun to the ground because of an airspeed disagreement between the Captains and Co-pilots airspeed indicator (ASI). The Captain had also engaged the auto-pilot which took its airspeed input from the Captain’s ASI which was apparently over-indicating significantly due to a blocked pitot tube. To cut a long story short, the over-speed warning sounded and there was confusion as to whose instrument was accurate. In an effort to reduce the (apparent) speed and silence the over-speed warning the Captain reduced thrust which, because of the low (real) airspeed, caused the aircraft to stall and crash.
Sadly the accident could have been prevented if the Captain had followed a simple but basic procedure on take off. During the take off run, the co-pilot called 80 knots and at this point the crew must confirm that both ASI are in agreement. If they are not as was the case with the 757, the Captain should abort according to the airline’s procedures. At this speed, this should not cause significant problems in most cases. In spite of this, unfortunately, the Captain noticed the discagreement but elected to continue with devastating consequences a few minutes later.
This episode caused me to wonder why it is we sometimes ignore or somehow amend tried and proven procedures. I suspect we all unconsciously undertake a simple risk analysis which due to the circumstances occurs in a fraction of a second, and due to a number of factors we get it wrong! Let’s be honest, in life we have all done it even if not in the aviation context.
The unconscious risk analysis however will sometimes be flawed because it cannot include all relevant information, the environment changes and or, often we have a situational inbuilt human bias which can rationalize any risk. A classic example of this is human bias is something like, “Get-home-itus” which partially compensates the real potential or consequence of the activity in our mind. So all aviation participants whatever role we play must guard against snap decisions which are contrary to procedures. We must be very disciplined to resist our biases and follow tried and proven procedures. Only on very rare and dire circumstances using all crew and other resources available to us, should be consider otherwise.
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