On Aug. 5, 2008, an overloaded Carson Helicopters S-61N crashed after takeoff from Helispot 44 on the Iron Complex Fire in northern California. Nine people were killed in what came to be known as the “Iron 44” incident, making it the deadliest firefighting helicopter crash in U.S. history. A National Transportation Safety Board (NTSB) investigation concluded that the helicopter was grossly overweight due to the use of falsified weight-and-balance and performance documents (which led to the conviction and sentencing, earlier this year, of two former Carson managers).
The official NTSB report on the accident noted that, two months after the accident, the Federal Aviation Administration (FAA) office responsible for overseeing Carson received two letters from different S-61 pilots expressing concern about the weight information and performance charts that were provided to the flight crew of the accident helicopter. The fact that these pilots came forward is admirable, but the timing is problematic.
While the Iron 44 incident may be a particularly egregious example of misconduct at high levels within an organization, the pilots’ tardy reporting brings us back to a recurring problem in industry, even in companies that strive for full regulatory compliance. That problem is: how do we get greater participation from line personnel in our safety and quality assurance programs? Professional pilots and technicians have sophisticated feel for the way their equipment — and their systems — operate, and are in the best position to know when something doesn’t feel right. The people on the line, who are closest to the risk, tend to know what is going on and how best to fix it. So why are safety management systems (SMS) and quality assurance (QA) programs around the globe suffering from a lack of engagement with those they seek to protect?
For the past few years, I have been asking this question to hundreds of line pilots and maintenance technicians, and their answers reveal a complex challenge. Here are the three most frequently mentioned reasons for not report, and what we need to do to correct some misperceptions and reengage the heart and soul of our workforce in our safety and quality programs.
“There was nothing unsafe about what I/we did.” This statement is emblematic of the biggest challenge we face, and an often-misunderstood aspect of how SMS and QA programs should function. In one example, a pilot explained that he reacted appropriately after being issued a difficult Air Traffic Control (ATC) request that ended up with an unstable, but eventually safe, approach and landing in a high density traffic area. This “I was dealt a bad hand, but I managed it” rationale for not reporting is at the roof of many future incidents and accidents. Pilots and maintainers who salvage a bad situation are often justifiably proud of their skill, and don’t see the event as a hazard to be reported. The key to this challenge is to understand that SMS reporting is not about what you did, it is about the hazardous situation you faced that others may face in the future. By reporting the event following your success in dealing with it, you are preparing the entire organization for the next time this happens — including those who might not have your skills.
“I don’t have the time and it’s too confusing.” First responders and their support personnel operate in a highly dynamic and often time-compressed environment, and any system that requires a lengthy or multi-step process or reporting is doomed to marginal participation. Far too many SMS vendors design the bells and whistles of their software to function for everyone making PowerPoint charts, but not those who have to use it in everyday situations and work environments.
I’m not going to rat out my buddy (or myself) to management. If it’s something we need to discuss, we will handle in house.” Once again, this presupposes the SMS/QA process is about finding fault rather than sharing information. The first order of business in any SMS or QA program is for management to define protections for reporting (making a clear distinction between an “honest mistake” and an act of willful non-compliance). The second critical task is for the senior safety or quality representative to build a bridge of trust to the line communities. This always means getting out of the office and into line ops environments, and often means standing up to senior management for those line personnel courageous enough to point out systemic safety challenges.
If we can reach out to line personnel on these three issues, perhaps we can begin to realize the potential of these critical programs. If we don’t, we can check the box on our next audit, and keep wondering why unfortunate events continue to occur.
Published in Vertical Magazine