For RJ Pilots and others

[Kip Powick]

Kip, no Canadian Forces pilot was ever punished as the direct result of a flight safety investigation. The CF flight safety system is - and always has been - totally non-punitive. If a commander thought that action should be taken against a pilot because of an accident, he had to convene a "collateral board" to gather information and make recommendations. The collateral board was totally separate from the flight safety board of inquiry and had absolutely no access to the flight safety investigation

..... I was on the board of an accident investigation, (ADC-YYB-1986) where the pilot was permanently grounded due to his incompetence. He was allowed to remuster as a CE Ofiicer but never flew again.... I was a member of the Flight Safety Board investigating the accident and our reccommendations were that this guy be permanently grounded...and he was. Yes, we were investigating the accident as well as his past flying history. We were NOT a collateral board and we had full access to every piece of info available.

[canadairguy]

our reccommendations were that this guy be permanently grounded...and he was.

That may not have been cause and effect.

[Don Hudson]

Kip,

re

Yes, we were investigating the accident as well as his past flying history. We were NOT a collateral board and we had full access to every piece of info available.

Be that as it may, no flight safety process today could possibly work this way. Nor does one example support the argument.

I would like to disagree with your view that unions "protect the incompetent". As there is with all professions, there is a range of skill level, competency and ability. I would submit that the record does not support the view that incompetence (whether cited formally or whether there was informal nodding agreement among peers) was a prime factor in the vast majority of accidents. If so, then we would need to bring in, with equal treatment and emphasis, an organization's training and checking programs as well as those kinds of programs that are supposed to provide feedback into the operations department (ASRs, FOQA), not to mention an examination of the initial hiring process.

We are all aware of the extremely powerful interests at work after an accident. The work of the pilots' union is to ensure proper and sufficient representation in the face of those interests. All too often, pilots are the 10k fuse in what quickly becomes a heavily fortressed legal environment where huge economic and political interests with seemingly unlimited financial resources and patience are at play.

Complexities and sub-issues over time can obscure these prime factors but it is crucial to keep them in mind.

SMS attempts to move the preventative and investigatory aspects into new arenas where both truth and change can occur. Whether it can do it or not is an entirely different matter but we are discussing attitude here, not process. We know there will always be lawsuits, one I have personal knowledge of lasting well over 20 years.

There is sufficient research material to categorically support the view that simply firing, dumping or grounding a pilot is a highly unusual and draconian process. This does not begin to address the question of why s/he was considered "safe" one day and not the next by the checking/training people. Unlike the military, the legal and financial implications are significant for private organizations.

This does not deny that individually egregious actions might occur. Nor is this a call to defend egregious cockpit behaviours which have little to do with human error. However, today's enlightened approaches to flight safety recognize the relative rarity of such occurences and deal with them through established Safety Reporting Policies which do not protect (nor should they) actions which are illegal or criminal in intent.

In terms of the Pinnacle accident, the aircraft was certified for 410 and both the stick pusher and the relight process were tested and certified. The crew did exhibit casual behaviour, but were they wrong in taking the aircraft to that altitude? Could they reasonably have expected to suffer core-lock? Did Pinnacle ever prohibit 410 cruise altitudes? Were mechanical issues such as core lock ever discussed/trained for? Did the crew calculate/discuss all these risks and still decide to climb anyway or were they so cavalier that they just ignored their training and all operational limitations? Were there two SOP standards unofficially at work at Pinnacle, whereby one knew how to pass checkrides and did things differently on the line? If the investigation stopped at the apparently cavalier attitudes of the two pilots, what would have been learnt? And finally, if the two pilots had survived the accident, should they have been fired, and if so, on what grounds?

I think it is fair to claim that these are open questions not easily closed.

Fascinating thread...thanks for starting it!

[Guest woxof]

In terms of the Pinnacle accident, the aircraft was certified for 410 and both the stick pusher and the relight process were tested and certified. The crew did exhibit casual behaviour, but were they wrong in taking the aircraft to that altitude? Could they reasonably have expected to suffer core-lock? Did Pinnacle ever prohibit 410 cruise altitudes? Were mechanical issues such as core lock ever discussed/trained for? Did the crew calculate/discuss all these risks and still decide to climb anyway or were they so cavalier that they just ignored their training and all operational limitations? Were there two SOP standards unofficially at work at Pinnacle, whereby one knew how to pass checkrides and did things differently on the line? If the investigation stopped at the apparently cavalier attitudes of the two pilots, what would have been learnt? And finally, if the two pilots had survived the accident, should they have been fired, and if so, on what grounds?

I think it is fair to claim that these are open questions not easily closed.

Fascinating thread...thanks for starting it!

1. a 1.8g pull-up shortly after takeoff to stickshaker warning.

2. Seats exchanged at 14,000 feet.

3. At 15,000 feet, a 2.3g pull-up to 17° nose-up followed by a -0.3g pushover.

4. Large rudder inputs left and right during climb

5. Through FL 240 the contol column was pulled back and released a few times over 30 seconds with rates of climb up to 5,000 fpm for several seconds.

6. Climbing at too high a rate and too slow speed for their weight to FL410 arriving at 0.57 mach instead of the 0.70 mach listed in the climb planning charts.

7. Much laughing at the aircraft's inability to hold altitude, nose up attitude and full ball deflection.

8. According to the original post in this thread, fighting the stick pusher three times.

9. Misleading ATC as to the nature of their problem.

10. Destroying the aircraft and very nearly other lives on the ground when they crashed in a residential area.

Of course Pinnacle didn't ever prohibit flying at FL 410. I'm sure they prohibited flying outside the envelope. Core lock was an unexpected event so would a company discuss something that is likely only familiar to design engineers. If you stall an airliner bad things may happen. Training, SOP's and company culture are legitimate things to look at of course, but at some point self-responsibility has to enter the picture.

If they had survived, at what point in the list from 1-10 would you as chief pilot say that they should be fired?

[handyman]

I have to totally agree with woxof on this one.

Had the pilots not act like backyard test-pilots with a kindergarten mentality this accident would likely never of happened.

It's not that they went to FL410 but the manner that they chose to get there. Had they survived, any Chief Pilot IMO would have done everything in their power to ensure these guys never flew again!

[ccairspace]

Fascinating thread...

Absolutely, Don. And I too thank Kip for starting it. It has poked and prodded many viewpoints into the light, all of which are valid and should be evaluated on their own merits, mostly because what is represented here is a reflection of the discussions that arise after likely all aviation incidents and accidents.

I had read that Popular Mechanics review of the Pinnacle accident before it was posted here and as I reread it again the same thoughts went through my head and initiated similar questions. Most prominently was the question of wilful negligence.

"The combination of high altitude and low speed once again triggered the Bombardier's stall warning system. First, "stick shakers" rattled the control columns and disengaged the autopilot to alert the crew of an imminent stall. When the crew didn't lower the plane's nose to gain speed, "stick pushers"

forced the control columns forward. The flight data recorder shows that Rhodes and Cesarz overrode the stick pushers three times and forced the plane's nose back up. At 9:55 pm, as they pulled up for the last time, both engines flamed out."

These were two “professional” pilots; what were they thinking?

In terms of the Pinnacle accident, the aircraft was certified for 410 and both the stick pusher and the relight process were tested and certified.

And, with reference to the FDR, all systems appeared to work as designed, well before the flame out.

Did Pinnacle ever prohibit 410 cruise altitudes? …were [these pilots] wrong in taking the aircraft to that altitude?

If the aircraft was certified for that altitude, why should Pinnacle have prohibited it? And if it wasn’t prohibited, then the pilots were not wrong to take it to that altitude. But what I simply cannot get my head around is why in heaven’s name did they try so hard to keep it there when the aircraft systems were leaping up and down, shaking their sticks and “hollering” to lose altitude?

Could they reasonably have expected to suffer core-lock?

I think so:

"…according to the climb profiles in the crew's flight manual, the maximum altitude for the 500-ft.-per-minute climb the pilots set was only 38,700 ft., based on the atmospheric conditions and the aircraft's weight that night. By operating outside the airplane's performance envelope, Rhodes and Cesarz subjected the engines to tremendous stress. The flight data recorder shows that soon after the crew ignored the fourth stall warning, the core temperature of the right engine reached 2200 degrees--almost 600 degrees above redline."

You will likely find it hard to discover someone more supportive of the approach taken by the TSB and the NTSB, when it comes to aircraft accident investigation, than I. Whether one compares accidents to chains, Swiss cheese or stew, the painstaking methodology used to determine causal factors and arrive at reasonable solutions to preventing their reoccurrence is more than laudable, it is outstanding. I have great faith that the NTSB will not be sidetracked by the core-lock issue, but Bombardier has now been saddled with a civil suit based upon just that. (I’m restraining myself before I get started on lawyers…) A lot of time and money will be spent defending that suit and the expenses will end up buried in the escalating costs of aircraft manufacture.

As for whether unions should come to the defence of pilots (in real time or posthumously), if not they then who? A defence must be vigorous but based in fact, and when all is said and done the Safety Boards will take all submissions into account when publish their findings. If there is something to be learned (and there always is) then we in aviation should take heed and learn it. In this case I believe it is how to teach respect and sense personal responsibility.

And finally, if the two pilots had survived the accident, should they have been fired, and if so, on what grounds?

Wilful negligence.

Pilots find themselves looking down at the buck dropped at their feet way too often when the error may indeed be their "fault". To even try and condone the actions of these two pilots I feel is patently unfair to the rest who try hard to maintain safety in aviation.

I will be reading the NTSB’s final report with great interest.

ccairspace

[Kip Powick]

It was a clear day over YOW. Blue skies and happy trails. We had a few pax in the back and WD was finding it a bit of a crunch to compete with AC in the triangle. The Captain, in my opinion, was not that competent on the A310….he passed his check rides but there were a few incidents in the SIM where I thought he was extremely border line(my last SIM was with him) ..but…hey what did I know, I had only been in civil aviation for about 8 months.

Our departure had us cleared to 5000 feet and as we lifted off, the Captain said he would like to see what the A310 could do in the way of a Max Climb Rate, climb. We continued at 18 degrees of nose up and as we approached 4000 feet I called “altitude-altitude” and we kept reaching for the stars. We were approaching 7000 feet with about 10 degrees nose-up pitch and I had one hand on the control column pushing forward, the other easing back the power and at the same time I was turning off Mode C. We bunted over at 8000 feet and the Captain torpedoed back to down toward 5000 feet as I explained to ATC that “we must have a faulty transponder and would recycle our squawk” , which I did, (turned Mode C back on)….. when we did our close to 1.5g pullout at 5000 feet.

The Captain was rather annoyed that I had grabbed the controls but after calming down he looked over and said I looked a little PO’d. Rather than bury myself with a verbal conflict in the cockpit I chose not to reply, (we FOs were on probation for a year), and busied myself with the goings on for the last leg of our pairing into YYZ.

I went home that night, wrote a memo to the CP about the incident….never even heard a word…no acknowledgement and never knew if anything happened to the Captain or not. (he has since left Canada).

If I had been the CP, the Captain would have had a talking to and would probably had his records pulled and probably be grounded for a month or so during which time he would have had a few SIM rides…..My point is ????? where/what were the consequences of initiating such an idiotic maneuver…we’ll never know if we came close to another airplane or what other poo-poo we could have got into …………. but if we had????

Thats when I started to notice that in commercial aviation there never appeared to be any consequences when one screwed up……and so far, I have seen little change……just a lot of talk about the “whole big evolving change in attitude and perception when looking at the entire big picture of an incident”…….. but few consequences for the very few that really overstep the bounds of professional airmanship.

Just my opinion, guys, just mine.

[Guest woxof]

So...... from ATC's point of view they let the crossing traffic stay at 6000 because as far as they were concerned it was just a faulty transponder?

[Don Hudson]

Woxof, handyman;

Thanks for your responses.

Re

I'm sure they prohibited flying outside the envelope.

, and,

. . . at some point self-responsibility has to enter the picture.

As per my post, I agree with these statements.

As I wrote, a Safety Reporting policy which guarantees a "safe" reporting environment with learning as the goal does not have the power to exonerate egregious or criminal action nor should it. When/if that occurs, the matter is clearly no longer purely a flight safety matter because operational discipline and professionalism have broken down.

Corporate discipline, legal enforcement or firings are a Flight Operations' responsibility and it would be based upon their own investigation, not flight safety's. That process, which has Flight Operations fulfilling their due diligence role, would go where it would go industrially but would remain independant from the flight safety investigation. Pilot Association defence would be as per established processes in the Collective Agreement (or similar arrangement) of the group involved as would be any crew's right.

Flight safety finds causes but does not assign blame. That's the main point I am making. My posts are about process. Whether that process is too forgiving, on-target, inappropriate to SMS goals or somewhere else on the landscape is the point of the debate.

[Kip Powick]

So...... from ATC's point of view they let the crossing traffic stay at 6000 because as far as they were concerned it was just a faulty transponder?

That would be the gist of it. Whether ATC knew we really busted our altitude is not known, nobody said a word about our "error" and my turning off Mode C was just an attempt to refrain from acquiring a violation.......I, we, never saw any traffic and if anyone saw us,,,they never said a word ...thankfully.

Our incursion would have probably only lasted one minute or less...it was all just a blur

[J.O.]

I went home that night, wrote a memo to the CP about the incident….never even heard a word…no acknowledgement and never knew if anything happened to the Captain or not. (he has since left Canada).

Kip:

Great thread! Some great discussion here once again.

It took guts to write that guy up, especially while on probation. I completely understand your disappointment in how that incident was handled. It certainly sounds like your skipper was one over which the Chief Pilot should have had nightmares. The fact that it wasn't dealt with in the manner to which you were accustomed from your past experience, may lead you to believe that all commercial carriers have a similar "old boys network" that protects people of questionable competence. I'm not sure that's a fair assessment. I certainly believe that a similar report would be handled in a more forthright manner at the airline I call home.

As one who deals with the non-punitive safety reporting process on a fairly regular basis, I believe that your report would not have met the test of a non-punitive human error incident. It sure doesn't meet the test for me.

[Kip Powick]

If they had survived, at what point in the list from 1-10 would you as chief pilot say that they should be fired?

Don

I think this post was directed at you. Just curious as to your response to the question...just curious.

[UpperDeck]

I think it was CC who said ;"don't get me started on lawyers" while at the same time stating that if the RJ was certified to FL 41,500, it wasn't unreasonable to operate at that level.

I believe this was a ferry operation. The job of the pilots was to deliver the aircraft safely AND ECONOMICALLY. No one here has referred to the manoevers described as a "joyride" but isn't that exactly what these two unfortunates were engaged in?

I honestly do understand the importance of seeking solutions that ultimately enhance safety but I justy as firmly believe that a "zone of silence" perpetuates or at leat sustains incompetence. There MUST be accountability because in the absence of same too many individuals feel unrestrained and it is restraint that permits society to function with some semblance of order and security.

A sterile investigatory process may be laudable for its goals but if in the end it insulates the incompetent or those lacking in appropriate judgement (as it must) then the ends may not be adequate to justify the means.

[IFG]

... but you are stretching my intent it by insinuating that I am " so proud" of the fact that there were consequences in the Mil when it was proven beyond a shadow of a doubt that a guy screwed up and he was gone. I was not “proud” but I, like others, was satisfied that the individual was gone/grounded and taken out of the equation. Your question as to "substantiation of proof" if this method lowered the accident rate is without answer, as you well know. How can one "substantiate the future"? However a decision to “cease flying” was made in the "interests of the future" and I see nothing wrong with that.

First, Kip, that little aside about "proud" was rather cranky, please disregard it - and I'll disregard in turn your inference that support for a more non-punitive safety culture can only arise out of some weak-minded PC inability to "call a spade a spade". BTW, I'm not usually accused of such reluctance - If necessary, let's call it a %^¢∑ing $#!+-shovel IMHO .

I don't expect you to "substantiate the future", but can you point to any empirical examinations of past experience that suggest punitive approaches increase safety. That one could perhaps place on the empty side of the scale to counter the wealth of support for the notion that non-punitive approaches do so. I confess I don't have links (and not being retired, also lack the time to hunt ), but I'm sure DonH (who has already touched on the subject with far more credibility than I) could point you, or one of the resident link-meisters. I can say that my view has been reinforced for a ¼-century in various courses, seminars, conventions, and countless articles and papers published in the best of our industry periodicals. It has been applied in other industries, and even the medical fraternity is coming round. I operate under the assumption that this is a debate that has been settled, with only a few remaining to be convinced, but truly my mind is open to opposing viewpoints.

Just to clarify, you responded to my post with a rhetorical question that bore no relation to the one I suggested (I had thought it was pretty clear ..? ):

.... What is the "pilots should never be criticized, nor should we say they were wrong" ( well we do say, at times, they are wrong but in very, very small print), attitude that seems so prevalent in this industry ? “Posthumous rebuke??”…..that the individual is dead is regrettable for all concerned but once again the trend in the airline industry is to dance around the fact that the individual screwed up…why??..is it out of respect for the individual or is it the fact that some pilots feel that their “Godlike” qualities, (in their minds), are beyond reproach, whether they are alive or dead?

If you think I want to thwart the investigative process and end results with the dismissal of valuable knowledge gained you are wrong. If you think I just want and cast "rebukes" on pilots just for the sake of saying they were wrong....you are wrong ..... If you think that I want the pilot community to understand that there is nothing wrong with telling one of their peers that they are not competent and are going to be let go/grounded...you are right....that's all my point is...where/what are the consequences for being stupid/incompetent ??? (other than death).

Accepting a premise (that there is no effect on the safety culture from the alternatives) then of course pilots could be criticised, disciplined, vilified etc to your, or my heart's content, Unfortunately, I reject that premise, as discussed above and in my previous post. I think your question is a false dichotomy. Turning to my query (without death by anecdote ), there are two reponses. Either you accept a less effective safety culture to preserve that of punity ... OR you let go of the imperative to punish for an improved over-all environment, and hopefully a reduction in harmful and tragic occurances. Unless ... you question that premise of my question, in the face of the evidence referred to above. What say you?

I'd also like to note that the civil environment may not be universally as forgiving as you and others seem to think. I certainly know of pilots fired after serious incidents, even pre-emptively, and I think you may agree that the Mil is not totally immune from protective buddy systems either.

A final thought - we're discussing this as if pilots are always "let off the hook" after a crash. Simply not true, pilots are cited causally with humbling regularity, and I'm sure the final report on Pinnacle's misadventure will do so. In spite of woxof's dire outlook of the outcome of ALPA's interventions and petitions, in the BEX case that he himself cites, the NTSB didn't change its assessment of the pilots' conduct one whit.

I join the others in thanking you for starting this conflab, Kip - the sort of stuff that makes this place worth coming to.

Cheers, IFG

[Kip Powick]

The question to ask is: are we better off tolerating a higher accident rate, satisfied that we occasionally but vigorously weed out pilots, or should we subordinate the disciplinary endeavor in favour of overall harm reduction?

If the above is your question then I think I answered it very clearly but in case you missed it …I will restate my position..

I am all for full and final accident investigations that, when completed, and published will hopefully prevent a reoccurrence of the same situation. I don’t think I have ever stated that I felt otherwise. The tone of your statement tends to make it look like I support just “hanging the accident perpetrator out to dry” and the hell with what caused it.

My point is that there tends to be a trend to “subordinate” punitive action no matter how conclusive the findings are that the individual screwed up. It now appears that pilots who finally find themselves with a large carrier have a “life-time” job no matter what they screw-up. I’m afraid that goes against my beliefs that one has to work within the set boundaries to maintain a job and no matter what, there is always a chance of unemployment should you pull a big “black” .

I understand where you, and perhaps Don, are coming from but I don’t agree with the trend. The only comparison I can give you in real life is a brief story that concerns my young nephew…certainly not aviation orientated but perhaps it will give you an idea where I sit.

The 6 year old kid was in Ottawa during the Tulip Festival and commenced tromping through the tulip beds smashing the crap out of all the flowers he could see. His parents pleaded with him to come out of the flower beds, he merely smiled and continued for about 5 minutes, kicking the snot out of the flowers all the while his parents pleading for him to stop. He eventually tired of his escapade and wandered out of the flower beds. His parents rushed to him and hugged him and murmured soft words of what a “good boy” he was for coming out of the flower beds.

My point is this…there were no punitive consequences for being a brat… and I see the same trend in aviation today…there are no consequences for action that should not be tolerated. I am well aware that there are numerous accidents that can not be attributed to pilot error so don’t conclude that I am advocating a lynch mob for every pilot that finds he is/was in a tough spot.

If this particular accident investigation actually points to core-lock issues, that's to the good, whether or not it was a primary cause. More appalling IMHO, regarding the apparent unawareness of the implications of a stall warning (!?), isn't it better to confront the possibility of other, unknown ignoramusses (sp? ), and attempt a remedy of that, than engage in a posthumous rebuke.

If this is your question , I already answered it in my response to your initial posting and perhaps clarified it, to a degree, above.

but can you point to any empirical examinations of past experience that suggest punitive approaches increase safety.

Com’on now…if a pilot is “tossed” how do we know what “may” have happened in the FS world however I do know of one individual who was given the boot, went on to fly as a “hotshot” at air shows and killed himself.

In most cases a pilot is “tossed” because the experienced individuals who make the decision feel it is was in the best interest of the aviation culture not to have this particular individual in the air. It is purely a judgment call based on supported data and the experience of the panel. You can not extract your desired “empirical” data from “coulda, woulda”………be reasonable.

Either you accept a less effective safety culture to preserve that of punity ... OR you let go of the imperative to punish for an improved over-all environment, and hopefully a reduction in harmful and tragic occurrences. Unless ... you question that premise of my question, in the face of the evidence referred to above. What say you?

You insist that there will be a less effective safety culture if consequences are brought forth for those that have been proven incompetent, or more seriously, have the attitude that the “rules” don’t apply. Just how do you arrive at that conclusion ? How about you give me an example of where a guy screwed up, was punished and flight safety culture was adversely affected.

Sorry, but you will have to put me in your category entitled “only a few remaining to be convinced”

To be honest I think we are beating a dead horse with respect to my outlook and your outlook. Glad you enjoyed the topic and even though, as you pointed out, am "retired" I do have other things to do in my life so will leave this issue to you youngn's who are creating the new world order.

[J.O.]

Kip:

I know we've had lots of discussion on this subject and we've agreed to disagree, but one thing comes to mind that I'm not sure has been said. Whether we react to an accident by assigning blame or by completing a thorough investigation where the human factors elements are addressed, the common thread is that either reaction is just that, it's "reactive". It's a response to something bad that's already happened. There are few, if any, "new" accidents these days. The mistakes that are made and/or the deviations from accepted practice that are taken, have all happened before in one form or another. If our reactive process was really effective, shouldn't we expect that a repeat of past bad events wouldn't occur? Obviously this isn't working, so we need a better mousetrap if we're going to improve the accident rate. An expert in risk management recently said that reactive safety programs are a waste of time (why close the barn door after the horse is already gone?). While I don't completely agree, he was right in the sense that true prevention comes from interrupting the accident cycle before the accident occurs. You need to keep the barn door closed if you want to keep the horses inside.

That's where the SMS safety culture comes in. In attempting to develop a safety culture through SMS, one of the most important elements will be proactive management of hazardous conditions and behaviours. The problem (as I see it) is that if we maintain a punishment culture, we will discourage people from reporting the hazardous behaviours (normalization of deivance or drift from accepted safety standards) that are precursors to accidents, thereby tying one of our safety hands behind our backs. They'll be scared to report for fear of being punished for a non-event.

Should gross negligence and willful acts be disciplined? Definitely. We must encourage professional behaviour and compliance. The problem has been that the "old way" of handling cultural deviations has been to punish the offender who gets caught, while allowing the rest of the deviators to keep on deviating. Like handing a speeding ticket to .01% of speeders, it doesn't solve the real problem.

Jeff

[Mitch Cronin]

Exactly!

Kip... I know you're not gone... so please indulge me a moment and listen to a simple example that comes from this ground-bound sector of the av-biz...:

1- Years ago, at an airline you're familiar with, a diesel had an engine replaced.... The engine that we hung was rendered junk as soon as we lit it up afterward, due to someone having dropped a bolt in a variable bleed valve opening....

Now if the culprit had admitted to his mistake, the ways of that particular airline would have had the fella that dropped that bolt spend 3 days "on the beach" without pay, for having made it necessary to change the engine again. (not to mention the cost of tearing it down to the extent needed to extricate the wayward bolt).

However, because he was silent, nothing happened to him (we never found out who it was)... but not only did the engine still need to come off, and be subjected to expensive tear-down, it was now a collection of several very expensive unserviceable parts!

2- Not too long ago - at another airline you're familiar with... A fella dropped a bolt inside an engine as he was attempting to remove it for an inspection, using the wrong tooling.... at that particular airline, though it doesn't seem to be written in stone, the culture is more of one that looks to correct, rather than punish... He immediately admitted his mistake. No consequence came his way, but he did receive some feedback on the use of proper tooling, as did we all, in hopes of preventing the same mistake from occuring again. That engine was not trashed.

Obviously the second scenario is better for all.... and the non-punitive method of error handling is evidently paying off. ... at least it sure did in that case.

[handyman]

Obviously the second scenario is better for all.... and the non-punitive method of error handling is evidently paying off. ... at least it sure did in that case.

Mitch your examples of dealing with errors reminded me of a story concerning a famous airshow pilot and a refueler.

The refueler was told to to put precisely sixty gallons of 100LL in his Shrike. Later, after take-off and at about 300' the engine failed and the aircraft crashed in a ravine tearing off the gear and severelly damaging the aircraft. Without injury and waiting for rescue the pilot could only think of one reason for the crash. A quick smell of the fuel confirmed his suspicion that the aircraft was fueled with jet fuel instead of 100LL.

printed in the Fullerton News-Tribune the next day was a quote from the airshow pilot. (When I got back to the field, I saw the boy standing by the fence with tears in his eyes. I went over and put my arm around him and said, "There isn't a man alive who hasn't made a mistake. But I'm positive you'll never make this mistake again. That's why I want to make sure that you're the only one to refuel my plane tomorrow. I won't let anyone else on the field touch it").

That airshow pilot was of course Bob Hoover.

People do make mistakes and that's when we should have compassion and strive to prevent it from happening again. But reckless disregard for procedures or regulations is different then just making an honest mistake.

[ccairspace]

People do make mistakes and that's when we should have compassion and strive to prevent it from happening again.  But reckless disregard for procedures or regulations is different then just making an honest mistake.

Ahhh... errr... um...

...

...

...

(deep breath)

We agree. Yikes!

Maybe there is hope for you yet...

ccairspace

[Kip Powick]

I said I wouldn’t but I will …to clarify.

I actually thought that I was pretty clear in putting down my opinion concerning the actions that should be taken when a pilot totally disregards the rules or continues to show incompetence. I find it hard to believe that the majority of the respondents feel I am out to hang every pilot, or mechanic, who makes a mistake. Some of you “dance” around the subject but are reluctant to commit to a course of action …woxof excluded, and feel that in most cases it is “hearts and flowers time” when someone really screws up.

I don’t think I can be much clearer but will try again. If an accident happens that is the direct result of incompetence, or flagrant disregard for the rules/regulations and the case is so proven by the investigative panel, the guy should be disciplined and in these circumstances a firing is probably the best course of action. I really don’t understand this “soft” approach to individuals who should not be employed in this industry.

The question keeps being asked, “can you prove that by punitive action you have enhanced Flight Safety?” Just how the hell does anyone prove that?? If the guy is fired how do we get any data that reflects an improvement in Flight Safety other than to say the individual is out of the equation and no longer “poses a threat” to our industry.. My rebuttal would be, “ prove that Flight Safety is enhanced by keeping the guy” . The answer is the same…you can not prove it other than, as time passes perhaps say “see he hasn’t screwed up in 10 years”……but is a company willing to take that chance. What if in 2-3-4-5- years he becomes a lawn dart…what then ??? Again, does a company want to take a chance??

I think woxof posted a great question concerning the unfortunate RJ accident…..how come no one has answered it ?…cause it’s not nice to pick on our peers ?, or cause one doesn’t want to be seen as a “hard-nose” concerning the future of these fictitious pilots??? Why..?. Why..?

MITCH re your posting………big difference…the incident happened on the ground and the consequences of such an incident do not come close to the consequences of a pilot out of control/incompetent etc in the air.

The question I ask you is…at what point does one say “what you have done is not acceptable and as a result you will be disciplined”? If you say “never” then I guess we will have to live with an outfit that really doesn’t care one way or the other about an individual failing to maintain their professionalism, no matter what the dollar cost, or worse the possible loss of life. Personally I draw the line at a certain point but it would seem that in today’s era that is not the PC thing to do… but rest easy boys, I’m not in the equation anymore…enjoy.

[J.O.]

Kip:

You need to start using this guy in your posts on this subject.

If an accident happens that is the direct result of incompetence, or flagrant disregard for the rules/regulations and the case is so proven by the investigative panel, the guy should be disciplined... The question I ask you is…at what point does one say “what you have done is not acceptable and as a result you will be disciplined”?

I believe that most of us have agreed with you on that. There's no room in the system for those kinds of actions.

If the guy is fired how do we get any data that reflects an improvement in Flight Safety other than to say the individual is out of the equation and no longer “poses a threat” to our industry..

You're right that it's hard to prove that one, but let me relate a story of how a punishing culture at one company seems to have failed miserably. This story was related to me during an SMS presentation, and I found it to be on point.

The company involved, which operated light twins carrying freight at night, had 3 accidents in 2 years involving gear-up landings. All three happened late in the night in a two pilot cockpit. In the first accident, the weather was crap, the landing gear warning horn failed to sound when the power was reduced below the preset level (I had that happen once), and the guys missed it. The Company's response was to fire the Captain.

Nine months later, accident number two. There was a newbie in the right seat, and ATC threw them a curve with a late runway change to accommodate another departure. The Captain accepted that change, but he was certainly overloaded when he missed completing the landing checklist (a violation of Company policy). Once again, the Company's response was to fire the Captain (a guy who was, otherwise highly regarded). By this time, the owner was developing a paranoid habit of whacking his guys for the slightest mistakes, and the atmosphere was pretty bad.

A year later, the third accident happened. During the flight, the Captain's instrument backlighting failed. The weather was crap, so the F/O was flying the non-precision approach. The Captain was reading the chart with a flashlight, and the ride on the approach was pretty bad. They missed the landing checklist (sounds familiar) and again, a gear-up landing occurred.

After the third accident, the owner decided that something wasn't working and he needed help. He hired a third party consultant to come in and see how things were getting done. The consultant did surveys among the employees, rode along on flights, and he reviewed the company's training records and personnel files. When he sat down to brief the owner on his findings, the first thing he told the owner was that his pilots and engineers were all scared of him and afraid to raise their safety concerns for fear of getting whacked. He then told the owner that in firing the two Captains who had the previous accidents, he had probably fired two guys who would be least likely to make that mistake again! He suggested that instead of firing Captain # 3, he needed to use that guy as a conduit for learning. The owner took the advice, and a slow process of cultural change began. That company is still in business today, and they haven't had an accident in years. By all accounts, the guys who leave for greener pastures today, do so reluctantly, and with fond memories of their experiences at that outfit.

Does this definitively prove that a punishing culture doesn't work and that a nurturing culture does? Maybe not. All I can say is that I'm seeing a similar culture begnning to develop where I work, and I believe we all will benefit over time. Will we continue to discipline people for flagrant disregard of the rules & regulations? I believe we will, but I also believe that a true safety culture will reduce the number of violations, as people realize that the desired standard is the safe and legal one.

Jeff

[Mitch Cronin]

KIP (one of these days remind me to ask you why it is you put a person's name in bold caps? )...

PC, shmeesee! That's got nothing to do with this debate.

Of course on the ground is different... I was trying to offer a simple example of how a non-punitive approach can indeed lead to a safer (less costly, in that example) environment...

If you're asking me at what point to fire someone, ...in the example I offered... I'd say it's as soon as you find out who dropped that bloody bolt and said nothing, thereby intentionally allowing that engine to be turned into minced metal. However... in that, and many other examples, including the flying world, where the punitive approach is the rule of the day, you encourage the hush.

I don't see why that's so hard to understand?... Obviously if Fred knows he'll get fired for a momentary brain fart during which he accidentally [insert whatever error here that he might get away with if no one saw it]... then he's likely to keep quiet about it and nobody can learn how easy it might be to make that same mistake. And maybe the next time someone makes that same mistake, someone could get killed?

And that's another point... even competent people make the odd mistake! Sometimes it's a resuult of fatigue... sometimes it's a result of poor training... sometimes it's a result of distraction... illness... or stupidity... etc... but how the hell would we ever know if you were to just go ahead and fire everyone who ever screwed up? Ya think you'd get any good insight into what might have led to their screwup if they knew the more they said, the more rope they were handing out for the hangman?

[Don Hudson]

Excellent post, Jeff...right on point.

Don

[IFG]

.... My point is that there tends to be a trend to “subordinate” punitive action no matter how conclusive the findings are that the individual screwed up. It now appears that pilots who finally find themselves with a large carrier have a “life-time” job no matter what they screw-up. I’m afraid that goes against my beliefs that one has to work within the set boundaries to maintain a job and no matter what, there is always a chance of unemployment should you pull a big “black” ....

.... To be honest I think we are beating a dead horse with respect to my outlook and your outlook. Glad you enjoyed the topic and even though, as you pointed out, am "retired" I do have other things to do in my life so will leave this issue to you youngn's who are creating the new world order.

Regarding the last bit, not that far behind you in birthdays, Kip, but I'll love being mistaken for a "youngn'" . If the horse has one more breath ...

I don't believe all the things about your opinions that you think I do. All of us here are committed (I hope) to safety in every way. It's an evolving process, tho' and nobody has a lock on the best way to achieve it, no matter what we sometimes say in the heat of discussion. I haven't meant to be adversarial, but re-reading my stuff, I know it looks that way.

I blew off the invocation of anecdotes, because I really do believe they can obscure the larger picture. Nonetheless, they are often illustrative of a point, and your YOW-A310 story twigged me. I don't think anybody here would go along with no repercussions for your crew-mate on that flight - we should not disregard the job of standards and training, and professional behaviour. But Don has referred to the separation that some of us believe should be maintained between that and safety/investigation etc.

Consider the role that a fear of violation played in the incident you related. It compounded an initially, let's say less-than-optimum situation. Had there been no fear of repercussion (a la NASA "free pass" in the US), the transponder might have remained on, the aircraft would not have once again crossed uncleared altitudes, a CADOR would certainly have been written (in addition to the crew's "timely report"), and the issue would have been brought into the open. While exempting the Captain from penalty for that specific event, if there was an ongoing problem, an official light would be starting to shine on it. Compared to the actual outcome, which offers the better opportunity for safety, and a possible resolution or remediation of skills or attitude?

Cheers, IFG [edited for sp & grammer. In a hurry, haste makes waste )

[canadairguy]

Two points.

Some years ago, as a military accident investigator, I investigated an incident involving a military aircraft which was undergoing heavy maintenance by a Canadian company. The central player was an AME who was an IAMAW member. Sadly, his union would not allow him to give us a statement. (He seemed to be embarassed by this and he was quite willing to answer our questions "off the record". ) If this happened again today would the union react the same way?

I was told by company management that the AME would probably be fired. They considered him to be one of their best mechanics but apparently their insurance company expected some sort of (punitive) reaction to the accident. If they did nothing, and he was ever at fault in a subsequent occurrence, they said their insurance rates would go through the roof. Is that really the case, that people are fired to satisfy insurance companies?