Not my Fault, Mon!

May 19, 2010 by Bruce Landsberg

Pilot-Cert-1“Accountability”  seems to be a most popular word these days,whether it refers to banks, government officials, oil company executives or pilots. The NTSB is hosting a forum this week on pilot professionalism which presumably will include a heavy dosage of accountability.  I admit to being confused because I always thought that the PIC title conferred that – no questions asked, regardless of the size of the aircraft or the part of the regulations under which the flight was conducted.

The professional side of the business generally does a very good job and their safety record proves it but there have been some very high profile lapses in past several years that obviously have attracted scrutiny.

The laptop lapse in the Airbus that over flew Minneapolis was irritating. A quote from a well-known captain in the NY Times: “Something in the system allowed these well-trained, experienced, well-meaning, well-intentioned pilots not to notice where they were, and we need to find out what the root causes are, he said. Simply to blame individual practitioners is wrong and it doesn’t solve the underlying issues or prevent it from happening.”

How is it the system’s fault when two professional pilots in a perfectly functioning aircraft manage to forget that they are flying eastbound at over 400 knots and should be landing soon? When do individual practitioners who are placed in position of absolute authority and there are two of them to be sure that they are looking out for each other, come to be accountable?

The Colgan accident had numerous failures from an undisciplined Captain who apparently didn’t understand the reasoning for sterile cockpits. He also didn’t quite get the importance of monitoring approach airspeeds and the autopilot while on a night IFR approach. Those are individual failures because I’m certain the airline Ops specs called for different behavior. However, the airline didn’t think that training in envelope protection was essential for pilots new to the aircraft – that is a systemic flaw.

In light aircraft with largely single pilot operations, we don’t have as many opportunities to blame “the system “ except possibly ATC. You ARE the system and when there is a systemic problem and it wasn’t a self-inflicted wound, please file an ASRS report. Even if it was your own doing – we can all learn from such incidents.

It’s said the road to Hell is paved with good intentions and best wishes. Unlike felony law where intention does make a difference, gravity and Newtonian physics make no distinctions – it’s all about avoiding the edges of the airspace and other aircraft. I will be curious to see how this NTSB professionalism forum plays out and there may well be some good ideas that come from it. But forgiveness is divine and no one flies without fault. The system should not be blamed and complex solutions proposed when the core problem resides in the mirror.

Bruce Landsberg
Senior Safety Advisor, Air Safety Institute

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  • Finbar Sheehy

    Two thoughts that come at this from different perspectives.

    1. I think a lot of the reason why people don’t accept responsibility, or “accountability,” is that it often simply means accepting blame/punishment. Letting yourself be punished for an incident that has already occurred, and that you cannot now mitigate, is something few people are going to sign up for. People who do step up and say “my bad,” usually do so when they know they will not be punished for doing so, e.g., the ASRS system.

    What we really want, however, is for people to “take responsibility”, i.e., to be proactive in situations where a bad thing has not yet happened, or has happened but could still be mitigated. If we want people to take responsibility in that sense, then we need to advocate it in terms that are not easily confused with letting themselves be punished. We want the pilot in command to “take command” (during the event) perhaps. Whether they “accept responsibility” (afterward) doesn’t help the passengers so much.

    2. I think it’s legitimate to try to push beyond “pilots were stupid/careless/tired/human” when trying to understand what happened. It’s not at all incompatible to say, a) these pilots did something thoroughly dangerous, even idiotic and b) a contributing factor to the idiocy was… and even c) a way to reduce the probability of idiocy is…

    We’ve berated pilots for their errors for a century. We’ve probably gotten 99.8% as far as we’re going to get with that approach. There isn’t a pilot aged under 140 who doesn’t know not to stall on the turn to final, and yet it keeps happening – even to experienced instructors. Looking for other causes doesn’t mean the pilots shouldn’t try not to make mistakes; it means that we recognize that further floggings may make us feel better but are unlikely to further improve flight outcomes.


  • Avi Weiss

    Bruce, Finbar;

    Concur with everything stated, and clearly “accountability” SHOULD mean “you make the (zero-day) mistake, you pay for it”. As Bruce points out, this abdication of accountability seems to be at the heart of many issues we have today as a society.

    That said, since we KNOW humans will make mistakes, it would be advantageous to examine the “the system” to see if any changes or improvements to it can be made to catch as many mistakes as possible BEFORE they lead to significant issues, like flying 400 miles past ones destination.

    I’m not sure exactly what systemic changes I would make in the “Category-5 Idiot” maneuver pulled by the Northwest pilots, but I’m sure if I spent enough time in postmortem analysis of “the system”, I could find something to improve/change to REDUCE the probability of it happening again. But again, no matter how much you idiot-proof something, someone always comes along with a better idiot.

    That said, determining that there are possible ways to improve the current system does NOT mean that somehow the current system should absorb any of the “accountability” of what happened in either of the two cases Bruce cited. These cases really involve GROSS levels of “dereliction of duty”, substandard airmanship skills and /or knowledge, and likely poor management oversight on training, and should be treated as such.

  • Kim Peck

    Bruce, good point.

    Although the pilot is ultimately responsible, also looking for systemic causes of a crash or event is good, and is the right thing to do. The hard part, is interpreting the results.

    An important contributing cause in both of the cited incidents, should be viewed as a lack of leadership. It is a problem of professional climate, culture, and attitude. I expect the pilots who take my money to act in a professional manner. They should have pride in their work because their skills have been verified by their seniors (or at least their peers) whom they and others, respect. The corporate entity should foster this atmosphere, not just go through the required motions. Clearly this did not occur. Sadly reality is quite different.

    In the Colgan accident, whomever who checks these airmen, dropped the ball. They not only failed to detect marginal piloting skills, they must have missed a problem of attitude and mindset. Diligence will not always make up for a lack of proficiency, but paying proper attention to the job at hand would probably have prevented both events.

    In the case of the NW pilots, the distractions caused by changes in corporate fortunes, scheduling and the ever present “seniority system”, could be called contributing factors. The proximal cause here however, is that the pilots allowed this to distract them.

    Pilots have been dealing with these distractions since the first airlines. What is ominously missing in both events, is the atmosphere of professional behavior. That is a problem of corporate leadership because, in the end, airlines are corporations. This points of course, to larger issues of our culture in general, but as pilots, we are all held to a higher standard.