From Bob’s Desk: Eliminating the need for ‘good luck’
By Bob Bacon
I am extremely proud of our people and our safety record. You could say I was even cocky about it. But the cockiness is gone, completely.
We have had two very serious incidents this month that could have resulted in much more serious injuries, if not for good fortune. Good fortune is not a good basis for a safety program — it is extremely unreliable. We need to be even better at eliminating the need for good luck.
Aviation accidents are studied extensively and research shows that accidents are preceded by a series of events or circumstances that can make accidents much more likely. This is called an accident chain.
The key is to understand what can cause the chain to start and how it can be broken. When I fly, I use checklists and I follow a routine. This routine can be upset by many things like: a distraction, flying from an unfamiliar airport, being tired or delayed, operating at night, or you feel pressure to make the trip. Checklists can help, but sometimes pilots just need to say this is a no-go situation, it is not safe.
As I think about our recent events, it seems the same for our work. Clearly using PPE, being properly trained and following proper procedures mitigates and eliminates the exposure to many hazards. Consider someone working at heights that slips and has their fall arrested by safety gear. There is no accident because the PPE did its job protecting our coworker. What if the same person forgot to clip in because they were worried about a sick child at home. People are human and humans make mistakes; they can slip, but we don’t want that slip to result in an injury or worse. This is where being a professional, checking yourself, the situation and clipping your lanyard properly breaks the chain of an unlikely slip resulting in a serious accident.
This is not simple. Even the best professionals have bad days. They get distracted and make mistakes. In Louisville in 2006 at 06:06 a.m., a Comair passenger jet with 49 people on board took off from the wrong runway and crashed. Only the copilot survived. Several errors were made, but the cockpit voice recorder indicated the pilots, copilot and possibly another passenger pilot were distracted and engaging in casual conversation before and while taxiing and didn’t do a thorough briefing before taxi or takeoff:
The NTSB determines that the probable cause of this accident was the flight crew members’ failure to use available cues and aids to identify the airplane’s location on the airport surface during taxi and their failure to cross-check and verify that the airplane was on the correct runway before takeoff. Contributing to the accident were the flight crew’s non-pertinent conversation during taxi….
This is a horrible accident and it was a fairly easy mistake for the pilots to make. The runways were close together, it was early and still dark and they had likely done it before. But, they got distracted and failed to double check things. What if they had done a HA (hazard assessment)? Would they have been more careful? Would they have considered things differently to break the chain?
Our work is always the same and always different at the same time. HA’s give us the chance to consider all the different factors, who supplied the equipment, are we working in the middle of the night, has everybody been using their PPE correctly, how many blue hats are on the job, and am I taking this seriously? Highlighting and recognizing what is unique to each job will help us identify what could go wrong. By being thorough and confirming what we know and not what we think we know (I think it is disconnect — it’s not the same as I know it is) will make HA’s more effective at identifying and breaking accident chains before they happen. Using the HA’s should facilitate a conversation between all the workers, discuss the work and the associated hazards and how to mitigate the hazards.
You are all professionals and our safety record is impressive, but our work continues to contain hazards and everyone make errors and mistakes. We need to continue to work hard to identify and eliminate the need for good fortune. By identifying situations that present additional risk and breaking the accident chain we will get to another safety level.