Time will tell, but I am worried.
Wednesday, January 15, 2014
W. T. F. ?
“The landing was uneventful, and all customers and crew are safe," airline spokesman Brad Hawkins said in a statement late Sunday.”
“Airline spokeswoman Brandy King said Monday that the captain and first officer were removed from flying duties while the airline and federal aviation safety officials investigate the mistake.”
Of course Jay Leno had some funny things to say about the mistake, but there is a very serious side to the incident. These two statements from the same news report of SWA 4013 totally contradict the other. How can the flight be uneventful and the pilots taken off flying status for their mistake? What was meant by spokesman Brad Hawkins “all customers and crew are safe”. I guess that was because they were no longer on the airplane. Before the airplane landed, “the outcome of the maneuver” and the safety of the customers and crew was clearly in doubt. Fortunately luck overcame human failure.
Last November I posted an article, Do Pilots Rely OnAutomation Enough?, after the “Dreamlifter” 747 flown by Atlas pilots landed at the wrong airport in Kansas. The anecdote for this or any other type of pilot error is the acknowledgement and ownership of the statement “I AM CAPABLE OF MAKING MISTAKES”. Pilots without that mindset, no matter how proficient or experienced, will continue to fall prey to their human vulnerabilities.
I am beginning to believe that the culture of the airline industry in general is actively trying to avoid this truth. I am very reticent to highlight specific operators. However, in this case it is unavoidable. I believe we are looking at the tip of an iceberg. The unusual number of recent incidents at Southwest Airlines requires either an internal or external audit of their flight operation. This audit is necessary to identify corporate attitudes and cultural attributes, both positive and negative, so that these lapses in safety can be addressed.
The audit needs to a Line Operational Safety Audit(LOSA). The goal of this audit should be targeted at the operations’ approach to safety, not just an audit of procedural compliance. I am sure that Southwest, like all other airlines, has sufficient procedural guidance to enable its pilots to avoid their string of recent incidents. So one must ask then, how does this continue to happen? And more importantly, how do we change the outcome? The LOSACollaborative, under the direction of Dr. James Klinect, provides airlines with the tools and training necessary to audit their operation and assess the collected data. It also allows for normalization and distribution of data between member airlines. All aviation professionals have a vested interest in the pursuit of the highest level of aviation safety.
Nearly 20 years ago, a Continental Airlines DC-9 landed gear up at Bush Intercontinental Airport (IAH). Even though no one received even a minor injury, the airline’s management took a courageous approach to that profoundly avoidable accident. Instead of looking at the accident as just a failure of the pilots, they looked at the operation as a whole. Just like the 737 crew landing at the wrong airport, the DC-9 pilots had SOP’s in place that would have prevented the gear up landing.
The paradox was, and still is, “What is the procedure that ensures SOP’s will be followed?”. How do crews escape the inevitability and consequences of human error? Humans CAN and WILL make errors. The only solution is to accept their existence. The only antidote is mitigation. As humans we cannot successfully avoid or ignore errors. They must be embraced and accepted as inescapable. Unfortunately, pilots like other very proficient and highly motivated individuals are the least likely to accept their fallibility.
It took the leadership of Continental CEO Gordon Bethune, the commitment of flight standards and training, the guidance and research of Dr. Robert Helmreich and his team at the University of Texas, and the willingness of the line pilots to develop the safety management approach we know today as Threat and Error Management (TEM). LOSA is an integral component of an effective TEM program.
I have asked this question many times, “Is the goal of airline operations safety or procedural compliance?” Will procedural compliance guarantee safety? Is having a published procedure a guarantee that pilot errors will be eliminated? Is it just process or the achievement of an objective?
I will agree that landing a 737-700 on a 3700’ runway is an impressive piece of airmanship. However, like performing surgery on the wrong body part, doing the wrong thing well is still doing the wrong thing. The last time I had surgery done the team in the operating room asked me a list of questions that ensured they were dong the right thing to the correct part on the intended individual. Just requiring a list of questions, i.e. creating SOP, will not eliminate error. To do that requires a mindset that includes the acknowledgement of error. Not just error in general, but that each person involved might be the one to make the mistake. The understanding that SOP is not the ultimate goal. Rather, it is a tool to manage error. When that mindset exists, the individual and the organization are able to look at threats that exist in them or their environment that causes humans to make unintentional errors.
Time will tell, but I am worried.