Wheels Up

Like the best of us, McLeod Governance has been known to fall into the trap of assuming that only recent events / studies are worthy of discussing and that the passage of time corrodes the usefulness of dated data analysis.

Never could this be further from the truth in this case of a study released 20 years ago.

The study still holds valuable lessons not only in terms of its subject matter – the causes of aircraft accidents – but in the way that assurance providers can, and should, seek to add value by providing interested spectators with a deeper level of understanding of root cause failures.

The study is by the National Transportation Board (NTSB) – an independent United States Government agency responsible for civil transportation accident investigation. In this role the NTSB investigates and reports on aviation accidents and incidents, certain types of highway crashes, ship and marine accidents, pipeline incident and railroad accidents.

The January 1994 study was titled A Review of Flightcrew-Involved Major Accidents of US Air Carriers, 1978 Through 1990 (reference: Safety Study NTSB/SS-94/01, 1994).

McLeod Governance takes no responsibility – if after reading this entry – you never want to fly again or you unnecessarily delay the ontime departure of a flight whilst you check the bona fides of the flight crew.

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The study analysed 37 accidents.

The captain was the flying pilot and the first office was the non-flying pilot in more than 80% of the accidents

73% of the accidents occurred on the first day the captain and the first officer had flown together.

Within that set, 44% of the accidents occurred on the first flight together for the captain and the first officer.

55% of the accident flights had departed late or were operating behind schedule prior to the accident.

Half the captains had been awake for more than 12 hours prior to their accidents, and half the first officers had been awake more than 11 hours.

Crewmembers who had been awake longer than these median values made more errors overall and specifically more procedural and tactical decision errors, than did the crewmembers who had been awake for less time.

43% of the accidents occurred between 2pm and 9.59pm local time; 30% occurred between 10pm and 5.59am the next morning and 27% occurred during the period 6am to 1.59pm.

The majority of the accidents occurred either during takeoff (27%) or landing (51%).

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That is the context.

Now the really interesting part from the perspective of anyone ever interested what can go wrong when the fundamental elements of a strong internal control environment – procedure compliance; communication; monitoring – are missing.

Of the 302 specific errors identified in the 37 accidents, the most common were related to procedures, tactical decisions and failure to monitor or challenge another crewmember’s error.

Monitoring / challenging failures occurred in 31 of the 37 accidents.

The type of error most frequently unchallenged was a captain’s tactical decision that was an error of omission.

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We therefore have a situation where planes crashed because there were poor information and communication protocols within the cockpit.

Worse still – for whatever reason – there appeared to be some sort of hierarchy in the cockpit which left poor decisions by the most senior person (the captain) unchallenged.

We can dismiss such findings as relevant to aircraft crashes alone.

We do so at our own folly.

How many times has a poor decision within an organisation gone unchallenged solely on the grounds that the most senior person in the room (or the company) has expressed it.

Honestly Lay Bare has always thought that there is a key element missing from a strong internal control framework.

Alongside tone at the top; risk assessment; policy and procedures; information and communication; monitoring we should add another pillar – that of courage.

How many accidents could have been averted – and how many companies could have been saved – had those who knew that something was amiss had the courage to say so.

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