Reflections After an Accident
- Issue 3/2010
- Copyright and Credits
- Guest Editorial
- Vitorio Stana: 2010 Transport Canada Aviation Safety Award Recipient
- To the Letter
- Flight Operations
- Feature: Creating a Picture of Risk
- Maintenance and Certification
- Recently Released TSB Reports
- Reflections After an Accident
- Accident Synopses
- Regulations and You
- Debrief: Take 2 on Helicopter Helmets: Todd’s Story
- FLYING ON BOARD SEAPLANES/FLOATPLANES (poster)
- Take Five: Underwater Egress
- Full HTML Version
- PDF Version
by Gerry Binnema. This article was originally published in the Nov.–Dec. 2009 issue of the Aviation News Journal (www.aviationnewsjournal.com) and is reprinted with permission.
A friend of mine died in a glider accident this spring. He was an amazing pilot and a really good guy. He used to fly jets in the CAF [Canadian Armed Forces] and then flew 747s for JAL [Japan Airlines]. He was an instructor out at the glider club, and I looked up to him because of his competence, confidence, and the excellent decision making that he displayed.
So what happened? A series of decisions, combined with poor conditions, led to him being just a little too low to return to the field. But it was really close. He could have landed in a small field a few miles away from the airport, but that would have resulted in damage to his brand-new glider, and it would have taken hours to retrieve his glider out of that field. Instead, he headed for a downwind straight-in landing at the airport, hoping for just a little lift on the way. What would you have done?
I know what you just answered. You would have taken the safe route. I would answer the same way. But research has shown that when we are actually in these predicaments, we often don’t take the safe and sure route. Instead, we often gamble.
Let me give you a less dramatic scenario, and I want to encourage you to be honest with yourself about how you would respond. You are driving down an unfamiliar road. You passed a small town about 20 minutes ago, but since then, you have not seen any sign of civilization. You have no idea about what is coming up next or how far it is to the next town. Suddenly, the little fuel light comes on. You have about 30 minutes of highway driving until your car runs out of gas. What will you do? To be safe and sure, you would need to turn back, but how powerful is the motivation to press on. There should be another station up ahead!
As humans, we hate to lose. So it is very difficult for us to make a decision that we know will result in a loss.
- We hate to turn back for gas when it means losing an hour of our time.
- We hate to cancel a flight when it means losing face or losing a customer.
- We hate to commit to a precautionary landing when we know it will mean damage, not to mention a huge hassle to get the aircraft out of a farmer’s field. So to avoid the known loss, we are often tempted to take a risk.
- There should be a gas station just ahead.
- The weather for the trip isn’t that bad, and we could always turn back if things turn out badly.
- I can probably make it back to the airport.
What we fail to do is look at the probability and severity of a bad outcome to the risk that we are taking.
One of the most studied decisions in recent history was the decision to launch the space shuttle Challenger on a cold January morning. That decision was exactly like the ones above. Cancelling the launch would have meant a huge loss to the shuttle program and a loss of face for the NASA [National Aeronautics and Space Administration] directors. When they asked the engineers about the risks of launching, no one could give them a clear, unequivocal answer. So they chose to avoid the known loss by taking a risk.
Of course, in hindsight, we now know that the Challenger launch decision was a bad one. And I now know that my friend made a bad decision on his flight this spring. But tomorrow, you or I might be faced with another similar decision. So how do we avoid making that bad decision?
First, we need to recognize this tendency and catch ourselves when we are in these situations. That isn’t easy. We make these kinds of decisions instinctively, and it takes work to recognize them. But we make these kinds of decisions in small ways all of the time, so start recognizing the little things you do, as practice. Next time you are exceeding the speed limit while driving, ask yourself why. The answer will probably be that you are trying to avoid being late for something by taking the risk of a speeding ticket. Next time you are doing home maintenance and are using a tool improperly or using a ladder that is too short, ask yourself why. The answer will probably be that you are trying to avoid the hassle of purchasing the right tool by taking the risk of personal injury.
Once you start recognizing your pattern for making these decisions, you need to give some deliberate thought to the risks. What are we afraid of losing?
- An hour’s driving time
- A revenue flight
- An insurance deductible and a great deal of time
What risk are we considering taking to avoid this loss?
- Reasonable probability of running out of gas in the middle of nowhere
- Reasonable probability of flight into IMC [instrument meteorological conditions], leading to a possible fatal accident
- High probability of a forced landing in an unsuitable area with unknown survivability
Once we consciously consider the alternatives, we often see things in a different light. Normally, our focus is on avoiding the known loss and not on the risks we are taking. When we start looking realistically at the risks, we can improve our decision making. Start practicing today to avoid making a really bad decision the next time you fly.
Gerry Binnema is an aviation consultant with an airline transport pilot licence (ATPL), an aircraft maintenance engineer (AME) licence, and a Master’s degree in System Safety and Human Factors. He has taught countless crew resource management (CRM), pilot decision making (PDM), and human performance in aviation maintenance (HPIAM) courses and is well versed in the safety management system (SMS) regulations. Gerry worked for several years as an aircraft accident investigator and as a Transport Canada (TC) system safety specialist. Gerry is also the author of TC’s “Pilot Decision-Making Simulator”, which can be found at www.tc.gc.ca/eng/civilaviation/
regserv/ safetyintelligence-airtaxistudy-simulation-decision_simulator-497.htm. He is deeply committed to saving lives through accident prevention. He helps companies with human-factors training and SMS development. For more information, please visit www.gjbconsulting.com.
Accident synopsis A09Q0126 in ASL 2/2010: comments submitted by pilot
In the “Accident Synopses” section of ASL 2/2010, the narrative of occurrence A09Q0126 (on page 27) ended with the following statement: Only the pilot/owner was wearing a seat belt. The pilot involved in the incident submitted additional comments and asked that we clarify the narrative. According to him, both he and his passenger were strapped‑in by four-point harnesses, and were also wearing inflatable life vests. The life vests were very effective in minimizing their upper body injuries in that they provided extra padding against the shoulder straps as they hit the ground nose first after falling about 65 ft from the tree-tops.
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