By Tony Kern, Ed.D
Chief Executive Officer, Convergent Performance
Adapted from Dr. Kern’s column in Skies magazine
I usually take great care not to talk about recent mishaps, and for good reason. Typically, emotions are high, and friends and family of the lost deserve the time and respect it takes to process the tragic events. But I’m going to make an exception this time, because the circumstances surrounding the crash on March 30, 2013 involving a Eurocopter AS350 B3 helicopter operated by the Alaska Department of Public Safety (DPS) have critical lessons for all who work in our industry. The National Transportation Safety Board (NTSB) issued their findings in November, and this report serves as the baseline for my commentary. For these reasons I feel the need to get a bit professionally uncomfortable.
The helicopter impacted terrain while maneuvering during a search and rescue flight near Talkeetna, Alaska. The airline transport pilot, an Alaska state trooper serving as a flight observer for the pilot, and a stranded snowmobiler who had requested rescue were killed, and the helicopter was destroyed by impact and post-crash fire. According to the NTSB report, “safety issues include inadequate pilot decision-making and risk management; lack of organizational policies and procedures to ensure proper risk management; inadequate pilot training, inadequate dispatch and flight following; punitive safety culture; and a lack of management support for safety programs.” In short, nearly every aspect of a healthy safety culture was missing, and had been for some time.
This was not the pilot’s first mishap. During its internal review of the pilot’s previous accident in 2006, in which the pilot became disoriented when his vision became obscured by blowing snow during a night NVG takeoff from a frozen lake, the Alaska DPS cited the choice of a VFR departure versus an IFR instrument departure as causal to the accident. This determined that the accident resulted, in part, from the pilot’s decision to perform a VFR rather than an IFR takeoff in the low visibility conditions.
In and of itself this is not inaccurate, but in their investigation, the DPS chose to ignore the systemic failures that led to this decision. Because the pilot was not IFR current in helicopters and the helicopter was not certificated or equipped for IFR flight, performing an IFR takeoff was not an option. According to the NTSB, “had the Alaska DPS’s investigation been more focused on identifying systemic safety issues, it may have identified that it had not provided the pilot with simulator training in IFR flying or inadvertent IMC encounters and had not imposed adequate weather minimums to maintain separation between the VFR-only operation and IMC. As a result, the Alaska DPS missed an opportunity to identify and correct some of the latent safety deficiencies that again presented themselves in the 2013 accident. Without improvements to pilot training and operational policies, the risk of another inadvertent IMC accident remained high. DPS investigations of other events also narrowly focused on the actions of the pilot while “disregarding the organization’s management of flight-related risks.”
I review dozens of mishap reports every year, and this common theme of dual failures–systemic blindness and poor personal accountability–raises its head far too often. Solving this challenge requires all of us to be willing to raise safety issues forcefully (but tactfully) with managers, operators, maintenance technicians, and if necessary, the regulator. These discussions can be socially difficult and professionally uncomfortable, but they need to happen. Here is what I recommend as a basic approach:
- First, realize that it is your professional obligation to raise safety issues to the right level. When you see a safety issue, ignoring it is not an option, at least for true professionals. The “right level” might be simply peer-to-peer feedback to a colleague, or taking a systemic issue as high as it needs to go.
- Second, have a plan and mentally prepare yourself for pushback. No one wants to deliver or receive bad news, but if you can do it with objective candor and genuine concern, much of the resistance will disappear. When you show that you care, others will as well.
- Finally, state your concern concisely, and if you are willing, offer to be a part of the solution.
It’s OK, and sometimes absolutely necessary to get professionally uncomfortable. It’s a hell of a lot better than going to funerals.
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