A great Swiss Air Force video shows us all how an enlightened high risk organization should use mistakes to get better, by moving away from a blame game and towards a learning culture.
If people get blamed for their mistakes, the only thing one achieves is that people will keep their knowledge about mistakes, safety gaps or dangerous situations for themselves.
Ask “why?” like a mantra to get deeper and deeper to the cause, to put yourself into the actor’s shoes and to understand, why the event had been happen.
Mistakes or incidents can be seen as free lessons. If we fail to learn from them, other colleagues will fall into the same traps because the holes/safety gaps are still there.
Good stuff. And it’s one of several Swiss Air Force safety videos on YouTube. Enjoy!
The 260+ page US Air Force Manual 11-248 lays out the rules and procedures for flying their T-6 primary trainer. This extensive 2011 publication for students and instructors gives a great explanation of flight discipline on the second page:
Powerful stuff.
Adhere to the spirit and intent of governing guidelines while executing the mission in the presence of temptation to do otherwise.
This quote is from the wonderful new documentary The Last Man on the Moon, that’s in cinemas and iTunes/Amazon right now.
Cernan’s love of flying powered his amazing career as a Navy fighter pilot, aeronautical engineer, and astronaut. He flew in space three times, including the last Apollo mission where he walked (and drove) on the Moon.
It became public this month that Qatar Airways has fired all four pilots in the cockpit when their Boeing 777 tail broke a set of runway lights during takeoff from Miami International last September. They mistakenly left from an intersection thousands of feet short of the planned full runway length. It was a serious accident, no doubt. There was a visible tear to the aircraft’s skin, the pressure vessel was damaged, and MIA airport needed some new approach lights.
Damage to aircraft and approach lights. Photo source, QCAA report.
The crew continued with the overwater thirteen plus hour flight uneventfully, apparently unaware of their close brush with disaster. But damage of this kind prompts an investigation. Airport security cameras recorded the airliner’s tail hitting the approach lights. So we know what happened. The real question is why? Was it a hurrying reckless crew? Or should we praise the flying pilot for sensing something was wrong and rotating just in time? And how serious was this?
Bending metal never is good. The damage was all fixable–about 18 square meters of damaged sheet metal, pressure vessel breached behind rear cargo door–but the possibility of a truly serious accident, of real danger to life, was certainly close. A little less performance, a little less runway, and continued flight may have been questionable.
The aircraft started the departure roll from the T1 intersection off a midfield taxiway, leaving less than two-thirds the normal runway length of 13,000 feet available for takeoff. That’s certainly plenty of pavement in a Cessna, or indeed an A320. But a fully loaded B777? Using a reduced takeoff power? Not so much.
Yellow line is aircraft ground roll. Photo source, QCAA report.
The Qatar Civil Aviation Authority (QCAA) preliminary report clearly details the event, and finds some compelling human factors that shed light on how an experienced captain (over 9,000 hours total time, including almost 1,000 on the B777) and three other pilots could think they were doing everything right. In fact, the report has no suggestion of recklessness, carelessness or intentional violations by the crew.
Zooming in on the taxi chart on a tablet may remove the ‘big picture’ view, leaving you to see a major intersection as close to end of the runway. It was a dark night. Planes landing on the runway were touching down close to the intersection, leading the relief pilots to think it was close to the end of the runway (but actually the landing threshold was displaced 511 meters). And both the captain and first officer thought they had the performance numbers for intersection T1.
Printout of on-board performance tool data. Photo source QCAA.
Unfortunately 09#T1 refers to “T1” engine performance conditions, not the “T1” intersection on runway 9.
It seems like a normal accident. A variety of engineering and human factors all lining up on a dark night.
So why have all four pilots been fired?
“At Qatar Airways we will not accept any kind of lapses by pilots because they have hundreds of passengers whom they risked.”
Oh dear. It’s the ‘fire and forget’ philosophy of flight safety (which is one step beyond ‘blame and train’). Stupid pilots. Bad pilots. Dangerous pilots. Now that they have been let go, the head of Qatar has publicly stated that passengers could rest assured the Miami incident was the “first and last” time it would happen at his airline.
The “first and last” time?
This one accident was a too-close high-energy brush with solid ground. But the message firing the pilots sends to every other pilot, bag loader, dispatcher, flight attendant and gate agent at the airline is a much more dangerous explosive charge. If you make a mistake, however easy due to poor engineering or bad luck or human factors or complex unforeseen interactions, and if you want to keep your job, you best be quiet.
While some media outlets praised the firing decision, “To say, this was the right decision on the part of Qatar is an understatement”, I am saddened. This totally destroys the open sharing of little incidents that lets us all change procedures and behaviors before a large accident happens. This is completely counter to the well-known and proven paths of Just Culture. This is against the philosophy of ASAP and NASA ASRS and UK CHIRP and SMS and just about any open safety system that is conducive to reporting, engagement and safety improvement.
If you “won’t accept any lapses”, on fear of firing, then your employees will not report any. However, I’ll bet you a billion dollars to a bagel that slips and errors and lapses and engineering complexities will happen. And one day, it will be CNN reporting what happened, not the friendly safety department.
It’s scary when management’s response to safety incidents is to offer a big steaming cup of STFU.
Let’s be careful up there. And share our experiences, fun or frightening.
