Does "Stuff" Just Happen? Unsafe Acts and Breaking the Accident Chain; discussion...

[FN FAL]

Does "Stuff" Just Happen? Unsafe Acts and Breaking the Accident Chain; discussion...

With all the tragic news related to commercial aviation in the past week, any thoughts on safety and accident prevention?

Have you broken the accident chain? I think we all have, many times over. As we go about our jobs and daily lives, consider what you are doing and if that little voice says, "think!"...listen.

Have a safe weekend, whatever it is you are doing.

The day I broke the accident chain

Fltlt Richard Brougham Everyone will almost certainly be familiar with the question, "Have you ever had one of those days?" The following is a story about my day off the rails, but I believe I ultimately made the right decision--as hard as it was at the time.

I was approaching the end of my tour on Hornets with a couple of major life changes: an impending marriage followed immediately by a posting to Qualified Flying Instructor's course. Needless to say, these upcoming events were causing some shifts in the focus of my attention. On the day in question I was programmed to lead a four-ship around the application pop attack pattern at Saltash Weapons Range which, in the Hornet scheme of things, is a relatively benign and low intensity sortie. The mission would be the first for the day and, combined with very tight range timings, would require us to brief immediately after the morning Meterological brief. After preparing the mission slides the previous afternoon, I planned to get to work early to deal with any last-minute changes; however, it didn't take long for this plan to depart the rails.

The next morning, a combination of a car refusing to start and then a truck with a wide load saw me arriving at work in a less-than-happy mood, and barely time to make it to the morning brief. After that it was a mad scramble, as there were changes to be made to the sortie plan due to worsening weather, but eventually we got the mission brief done. There was a further delay as I hadn't had a chance to get changed into my zoom bag; while this didn't take long, it was putting me further behind the time curve. We finally made it to the flight line to sign for the jets, where another irritant crept in.

The positioning of the high- and low-drag bombs on the jets was opposite to what I had briefed. Whilst this meant just a quick pen amendment and a mental readjustment of the positioning of the bombs, it further angered me, as ultimately the error in the briefing was due to my misinterpreting the information passed the previous afternoon. So, by the time I made it to the jet I was in a less-than-ideal frame of mind, but trying to put it aside and get on with the J-O-B.

The pre-flight walk around was quick, in fact so quick that for the first time ever I made it back to the front of the aircraft before anyone else. There was little time though to ponder this observation before the others appeared for the "thumbs up." So it was up the ladder and start strapping in, but I hadn't progressed far when the internal alarm bells started ringing that something was missing.. .the seat pre-flight! I had completely missed it in my rush. Back out of the aircraft, do the pre-flight, back in, strap in and on with the checklist. But by now the storm clouds in the cockpit were matching those outside. As I pressed on with the checks, the alarm bells started ringing again; I had missed another item in the checklist. After correcting that omission, I took a moment to sit on my hands to try to get myself back on the tracks. As I sat there I reflected on all that happened so far; all I could think was that it was like reading an accident story in Spotlight with all the links of the accident chain in place. This led me to the decision that if I made one more mistake I would consider pulling out of the flight.

It didn't take long before I reached that crunch point, when I realised I had jumped the flight controls BIT check. So, as I sat there in my perfectly serviceable jet contemplating my immediate flying future, a number of thoughts ran through me. The first was an obligation to try and get the job done, otherwise I would be letting myself and the team down. Another was the cold hard rationalisation that, based on my performance to that point, the risk of continuing the flight and making another mistake--or making a poor decision which could hurt me, or worse still, others--was not justified by any overriding operational or training objective. So it was with a heavy heart, but tempered by the feeling that I was breaking the accident chain, that I handed over to Dash 3 and shut down the jet.

Once back at the Squadron I explained to the Flight Commander what had happened and, later, repeated my story at a pilots' meeting after the day's flying. It was of immense relief to me that the others supported my decision and empathised with my anxiety in making it.

One lesson learnt was that education in the form of safety videos and magazines over the years made me realise that I was in a bad situation and heading for a potentially worse one unless I "broke the chain." Another was that during peacetime training there should be no hesitation whatsoever in any decision to stop if safety will be compromised--and that the decision to do so will be fully supported irrespective of the circumstances.

As a postcript, a few years after this event I read an article in RAE Air Clues where a very experienced Jaguar pilot found himself in an almost identical predicament of external pressures distracting him, resulting in a multitude of errors. He also experienced the same personal conflict whether to press or not, before making the same decision as I did: handing over the lead and shutting down the jet. In both cases the decision of not to press was the correct one.

COPYRIGHT 2003 U.S. Air Force, Safety Agency

 

[mar]

I'm gonna be a jerk and just say it.

Another was that during peacetime training there should be no hesitation whatsoever in any decision to stop if safety will be compromised--and that the decision to do so will be fully supported irrespective of the circumstances.

This is a luxury the civilian pilot just doesn't have.

No matter what sort of a day you're having, as a civilian, there's a schedule to keep and goddam it, if you're rested and the airplane is serviceable and the weather is legal then that flight is going.

If I had a nickel for every messed up, hung over, divorcing, bitter and bankrupt pilot I've flown with on a day to day basis over the last 10 years I could retire.

Get over it and be professional.

 

[FN FAL]

This is a luxury the civilian pilot just doesn't have.

No matter what sort of a day you're having, as a civilian, there's a schedule to keep and goddam it, if you're rested and the airplane is serviceable and the weather is legal then that flight is going.

If I had a nickel for every messed up, hung over, divorcing, bitter and bankrupt pilot I've flown with on a day to day basis over the last 10 years I could retire.

Get over it and be professional.

That's too bad that pilots work under those kinds of conditions...I was there at one time. My first 135 operator liked to try and push pilots.

My current 135 management respects the right and responsibility of a pilot in regards to decisions in initiating or terminating flights. They also have a reality based expectation that we will cancel flights if there is going to be problems with icing. Sometimes all you need is a couple of hours to let a front pass and you're on your way...and I don't have a problem with leaving the chocks on until that time comes.

On the other hand, we have a savy and experienced pilot group. If we can find any plausible way to make a safe flight to our destination, we will. It really helps when you got eight planes flying in same region, you never have to ask twice for a pirep from one of your own.

 

[mar]

That is pretty rare

Of all my bosses, I've only had one that would stick up for me.

But still, I'm pretty tired of whiney pilots. They wonder why they get treated like children.

This isn't flight school. We don't have the luxury of flying when we feel good.

A professional goes out there and gets the job done just as well whether he feels good or feels bad.

Not talking about icing conditions. Just talking about having a bad day. Everybody has them. Professionals don't drag that crap into the cockpit.

I mean, really, the dude in your story cancelled a flight because he had trouble starting the car, got a little road rage, rushed through a preflight, forgot a couple items on the checklist...

...so WHAT??

If I ever cancelled a flight for something like that I would be FIRED.

This is the real world.

 

[FN FAL]

Of all my bosses, I've only had one that would stick up for me.

But still, I'm pretty tired of whiney pilots. They wonder why they get treated like children.

This isn't flight school. We don't have the luxury of flying when we feel good.

A professional goes out there and gets the job done just as well whether he feels good or feels bad.

Not talking about icing conditions. Just talking about having a bad day. Everybody has them. Professionals don't drag that crap into the cockpit.

I mean, really, the dude in your story cancelled a flight because he had trouble starting the car, got a little road rage, rushed through a preflight, forgot a couple items on the checklist...

...so WHAT??

If I ever cancelled a flight for something like that I would be FIRED.

This is the real world.

True. Fortunately for us mar, we have our jobs down to the point where we can do them in our sleep. I never have nightmares with navy salvage divers in them...unless in the dream I am part of the salvage operation.

 

[mar]

Sleeping on the job

I won't say anything else about sleeping thru my job.

But I gotta tell you man, you make the most interesting segues.

Good luck.