Thursday, February 17, 2022

Underlying Factors

I'm re-reading the TSB Report on an air crash at Fond-du-Lac, in preparation for another class I'm teaching. At every step of the recounting, pilots who have never worked in the north will be crying, "What?" and "No!" while pilots who have may nod their heads with understanding. 

When I got to this sentence ...

Early in this investigation, it became clear that more information was needed to determine whether the underlying factors identified in this occurrence were present elsewhere in the Canadian commercial aviation industry.

... I said out loud, "Where have you been?" How can someone be working in accident investigation in Canada and need any more information in order to know that the underlying factors in that accident are omnipresent across the land? 

The summary refers to "the inadequacy of de-icing equipment or services at these locations."  Inadequacy doesn't begin to describe it. You'd be lucky to get potable water at Fond-du-Lac. They say, like it makes any difference:

There are many defences in place to ensure the clean aircraft concept is followed, such as regulations, company operating manuals, and standard operating procedures. However, all of these defences rely singularly on flight crew compliance.
And sure, that captain could have picked up that cell phone and called company to tell them there was too much ice on the plane and he was not departing. How would that have worked out for him? Well, probably better than the serious back injuries he received in the crash. That sentence should finish, "... defences rely singularly on flight crew ability to defy company expectations." No, the company doesn't expect crews to fly with iced up aircraft. They just expect you to fly, and don't want to hear about the difficulties.

I think five to ten percent of my training in anything is assuring pilots that I really want them to follow the regulations, the company operating manual, and the SOPs, that they won't get in trouble for cancelling a flight if the conditions aren't right, or for grounding an airplane with a snag. By the time I get them, and I'm by no means at the top of the aviation food chain, the industry has already taught pilots that there is one set of rules for the classroom and another set for the skies. I have to beat it out of them. And myself.

1 comment:

TgardnerH said...

It's not just your trainees--I am a significantly safer pilot than I would be if you never wrote this blog. (And if I never read your writing, I also might never have learned to fly at all).