Learning from Aviation Accidents and Incidents. By Owen Zupp.

 

 

Airplane simulator 

 

We in the aviation world are actually a little further ahead of the game. We don’t give ourselves enough credit, but while corporate entities strive to maintain a level of secrecy, aviation seeks to share its shortcomings. The dissemination of safety findings on a global scale in an effort to circumvent repeat occurrences is one of our industries greatest achievements. When faults are found with aircraft, or the way in which we may operate them, that information is freely broadcast. There is a level of operational maturity in aviation that has not been achieved overnight, but it is a work in progress we can all be proud of.

Air safety investigation has come a long way over the decades. Rather than simply attributing every smoking wreck to “pilot error”, our knowledge based has broadened to delve deeper. We recognise that the finality of an accident is the result of numerous factors slipping through the net before ultimately combining in a lethal cocktail. The pilot is the final line of defence and sometimes he is just not enough. Sure, there are still instances of rogue pilots blatantly contravening every rule of good sense, but fortunately they are in the vast minority.

From ICAO and the national regulators of aviation down to individual operators, the pursuit of safety is an ever developing challenge. At its very core, success lies in open, honest reporting. Everyone has the ability to observe and speak up and in its most basic form; this is one of the places where safety begins. It may be wrapped grandly in a formal reporting system, or bound in the pages of an official accident report, but fundamentally it is about being honest. Whether it involves reporting potential safety issues or dissecting a tragedy in hindsight, there is no room for cover-ups or misplaced silence. Well chosen words may save lives.

But the road is not paved with gold just yet. There are still companies and cultures that do not encourage ‘speaking up’; whether on the flight deck or on a written form. In these environments, the benefits of safety have still yet to take full hold. Only when aviation professionals feel comfortable reporting mistakes and transmitting ideas can the group work together to minimise risks. Generally referred to as a “Just Culture”, it is an environment that encourages open communication without fear of reprisal.

So what does that mean to a lone pilot sitting in his Beechcraft Baron on a dark, wet threshold about to open the throttles?

It means that they are not alone. Somewhere before, a pilot has executed the same manoeuvre and contributed to the pool of knowledge that better prepares the next pilot. On such a dark wet night there are many dangers lurking. Sensory illusions due to acceleration trick the mind and only the instruments can be trusted. What if an engine should fail? Am I able to return to land or is there an escape path? Nearly every scenario that can be conjured has happened before and whether it culminated in a fatal crash or a moment of cold sweat, there is a lesson to be learned. The facts may be discovered by sifting through the wreckage or analysing a flight data recorder. Happily, they may also be found through self-reporting by a sensible, living, breathing pilot.

By whichever means the facts should surface, pilots should grab them with both hands. Aviation is an ongoing process of education and this is never more applicable than when we have the opportunity to read or the near misses and misfortunes of others. To the outsider this may appear ghoulish, but to those in the field it is cherished knowledge. Often sobering, these tales of misadventure fill the accident report sections of journals across the world.

It is equally important that we remain impartial as we digest the cold, hard facts. For in the safety of our armchairs it is impossible to recreate the mindset of another, or to feel the pressures and distractions that may have led to some terrible omission or oversight. It is not our place to judge with the benefit of hindsight, rather we should glean every ounce of knowledge that can be stored away for use on our own dark, wet night. Often, the pilot will have paid the ultimate price for a perfectly human error and there is nothing to be gained from slurring the reputation of another. In fact, such talk infers a sense of superiority and a belief that the mistake was merely simple and stupid. Beware! There is no room for such complacency in aviation.

I once watched a filmed re-enactment of the final approach of an ill-fated airliner. As the final stages of the approach became more hurried and communication more confused, error after error began to surface with increasing frequency. But rather than sitting in judgement, the hair rose on the back of my neck and a doomed sense of empathy with the crew stirred in my guts. I sat in air-conditioned comfort, knowing the final outcome of this approach, but equally I recognised the conditions that had placed this aircraft and all onboard in harm’s way. I could see the lurking demons of weather, systems failures, commercial pressure and fatigue stalking the hapless crew and I wanted to warn them from my comfortable chair. But it was all to no avail.

Far from sitting in judgement, I tried to take something from the tragic outcome that would improve my own operational performance. And so should we all when presented with safety information or the findings of an accident report. As with 'The Fatal Stall', from time to time this aviation blog will re-visit a range of aircraft accident and incidents in an attempt to enhance the safeguards in our own flying. There will never be any judgement placed on those who have ‘stared down the barrel’ in the accidents we review, rather we will endeavour to draw some positives from an otherwise unfortunate outcome. Nor will there be any sense of complacency, for there but for the grace of God, go I.


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