Above reproach?

December 30, 2009 by Tim McAdams

Commenting on my gross weight blog, Harold wrote:

“Leave the flying to he who is in the cockpit and the finger-pointing blogs to another publication please.”

That got me thinking, when is it (if at all) appropriate to comment, criticize, or even intervene on another pilots actions or behavior? I understand and agree with Harold to a point, but I don’t believe the complete answer is all that clear.

I have studied and written about helicopter accidents for many years. I think most of them have a lesson that can help us all be better pilots. I try to write about these in a way that states the facts without expressly passing judgment (gross weight included) and let the readers draw what they want from the situation. Believe me, I have made my share of mistakes but I have been lucky because they didn’t result in an accident. I have viewed them as learning experiences, because had something been just a little different I might not have been so lucky. I like to tell people that I can’t promise I won’t make a mistake, but I can promise I won’t make the same one twice. Having studied many accidents it is clear that there are no new accidents only the same ones repeated over and over, just in a different manner.

I also believe that simply being a licensed pilot does not make you above reproach. Listed below are three examples of pilot behavior that other people knew was dangerous. A link to the complete NTSB report is included because all the details can’t be listed here.

A pilot flying a news helicopter was well known as a hotdog and the photographer riding with him had expressed concern. His last radio transmission was “watch this” as he pulled the helicopter vertical and severed the tail boom killing himself and the photographer.

http://www.ntsb.gov/ntsb/brief.asp?ev_id=20001212X20685&key=1

A very experienced tour pilot flying in the Grand Canyon was well known for being a skilled pilot and for his aggressive flying. He had earned the nickname “Kamikaze.” At high density altitude he slammed into a canyon wall killing himself and six passengers.

http://www.ntsb.gov/publictn/2007/AAB0703.pdf

A pilot continued to fail phase checks, check rides, and pre-employment rides. He eventually got a job where his flight skills were not evaluated prior to being hired. He crashed an R22 killing himself and a passenger on an introductory flight.

http://www.ntsb.gov/ntsb/brief.asp?ev_id=20060228X00255&key=1

I really appreciate all the professional comments that people post. So if this subject interests you please take the time to read all the details and let us all know your thoughts. I believe that approaching this topic in the correct way can be a powerful learning tool for those so inclined to listen.

My intent is not to point fingers but to get pilots thinking about how easily an accident can happen. I know that reviewing accidents has helped me be a better pilot. However, I am very curious if other pilots find this helpful.

One final thought. I have been involved as an expert witness for helicopter accident cases in court and believe me the intense scrutiny pilots endure is not pleasant. Seeing that has given me another reason to believe that being ultra conservative to avoid an accident is well worth it.

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7 Responses to “Above reproach?”

  1. Jon S Says:

    Tim, you’re absolutely right–studying the causal factors in accident, incidents, and close calls is the best way for us to prevent recurrences of those stories. As it has been said, if we don’t learn from the past, we are destined to repeat it.

    When we’re picking the events apart, it is hard not to sound like we’re pointing fingers, and that’s probably why the NTSB avoids getting too much into the human factors in their reports. Unfortunately, as we know, human factors are THE biggest factor in accidents. We need to try to understand not just what happened, but why accident pilots made the decisions they made. So, we need to keep talking about the mistakes we all make–especially those that end the worst–and applying CRM, we focus on what is wrong, not who is wrong.

    Keep up the great work, Tim.

  2. Tom Hurley Says:

    I believe we all as pilots, dissect each accident we hear of and usually come to the same decision when warranted….. What was the pilot thinking? I’m sure no pilot intentionally drops from the sky by doing something that they know is not a prudent move. Its more than trying to fly anothers aircraft or second guessing the pilots actions. Reminding pilots sometimes our decision making may not be what it should be is as important as a following the checklist before each flight. I thank aviation writers like you for opening our eyes to the accidents of others. I’d rather be judged by pilots than by ground pounders.

  3. Keith Blair Says:

    Tim, I agree with Jon and Tom. The NTSB accident reports are valuable learning tools that can help save the lives of others if used as a proper discussion mechanism. It would be a disservice to those who lost their lives while flying to not talk about an accident and learn from their mistakes. As a Coast Guard pilot, one of the things I love about the organizational culture is our candidness about personal error in aviation. Our mishap reporting system informs the fleet when there is anything from a minor lessons-learned incident to a major mishap. In most wardrooms, we have periodic pilot meetings where pilots will talk about their own mistakes or other lessons so that others can learn. As a matter of fact, my unit recently reviewed a mishap report that just came out about an accident that claimed 4 lives last year. Many in the audience were personal friends with the crew, but we used that mishap as grounds for a frank discussion on in flight emergencies. As was mentioned, it’s often a fine line between pointing fingers and trying to learn what could prevent a similar act in the future. Any discussion should be carried out with the respect anyone of us would want.

  4. Avi Weiss Says:

    Tim;

    I re-read your original “gross weight” post, and I must have missed the “finger pointing” element that Harold detected. While the analysis is somewhat “anecdotal” in nature relative to actual details, as I pointed out in the comments in the original post, the point being made about the “casual nature” many pilot bring to the weight and balance exercise is spot-on.

    I would concur that there is little value in “blame assessment” from a pilot’s perspective, and best left to FAA enforcement personnel and perhaps those partaking in the tort process. But I ALSO believe that it is incumbent on every pilot who wishes to be the best pilot they can be to thoroughly analyze the actions of other pilots “practicing the art of aviation”, especially if those actions result in flights that come to grief. In those cases, careful review of the all the elements of the accident “chain” is not only prudent but an important aspect of the continual learning process all pilots should be actively engaged in.

    Reviewing and “critiquing” other pilot action not only brings insight to the operational details at issue, but also the “human factors” elements such as decision making, which are sometimes easier to observe in others actions, rather than our own. ALL “practice-based” professions (lawyers, doctors, etc) have a aspect of “professional conduct review” which looks to objectively review the facts of a particular situation, and work to understand all the salient facts, so that everyone can learn from the situation. Aviation should be no different, although we unfortunately are not allowed to “self police”, and have an outside agency watching over our shoulder. However, that should not stop those of us who strive to be the best we can be, to continue to write blog posts reviewing accident information, and to comment on those blogs to generate the “give and take” that helps us all move forward.

  5. Brendan Fitzpatrick Says:

    Good thoughts – one can’t make all the mistakes so best to learn from those that do. Thanks for this blog – keep it up and Happy 2010!

  6. Alex Kovnat Says:

    The last two issues of Vertical magazine (The Pulse of the Helicopter Industry), had articles on “the stupid things we do”, including the “watch this” syndrome, taking off without doing a thorough preflight inspection, and so on. Some of the stupid things mentioned, are applicable to fixed as well as rotary wing aircraft.

  7. Chris Says:

    In many professions, part of learning and career development includes constant peer and self-critique. Even in these fields, it’s hard not to take or deliver the criticism personally, and everybody involved needs to realize why there is a culture of critique: to improve both individual and institutional practices. This is especially important in environments where making a mistake can end a life or career. Even second-guessing another’s decision-making raises valid issues, even if they weren’t ultimately relevant.

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