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All accidents are not preventable by Anonymous.

The cry of helicopter Aviation Safety and Management seems to suggest that all accidents are preventable. While I applaud and support the efforts to reduce accidents within our community and hope serious calamities are minimized, I'm not willing to concede that the concept of Zero Defects is, in the long run, practical or even beneficial. I posit that the very existence of accidents is demonstrative of the predisposition of the human condition, namely our own imperfections. Furthermore, it is the positive response to accidents which is the seed for our greatest improvements and achievements (a case I should not have to make).

First, one should understand that the word "accident" defines an unplanned event. After all, nobody plans to have an accident. My 86 year old Mother does not plan to break her hip - she tripped. My son didn't plan to have a woman run a stop sign from a blind intersection in front of him – so, even though he was driving safely, he hit her car. These occurrences are a part of life’s fabric – people fail. We trip, fall, forget, lose, become distracted, move too quickly or not quickly enough, don’t perceive, don’t listen and don’t communicate… we err. We are not perfect and any number of safety practices will not change that condition, it’s endemic to mankind. How we respond to our imperfections is what improves our condition.

It seems to me that the response of the Helicopter Safety community is to analyze every accident and impose another restrictive (say, “safe”) practice which is developed after the accident. Please understand, it’s not that I am opposed to our efforts; I stand opposed to the thought process that suggests system modification is an answer to all mishaps. Corrective action (such as changing checklists, procedures, and adding systems) assessed to every anecdotal mishap with little regard for the consequences of poor personal choices is counterproductive to our overall performance as an industry and counterintuitive to real progress.

Let me give you some examples how this thought process invades our behavior.

The FAA tells us that it is safe to fly a twin-engine helicopter over water (with certain performance limitations). We submit to that restriction but, that’s not good enough – we want more! Perhaps we need floats and then it’ll be safe. No that’s not enough, we need more, so we add life rafts/survival kits in the aircraft. That’s safe, isn’t it? No, we need more; we need to be wearing life vests. Wait, maybe we need actual water training in a dunk tank…and the layers are added ad infinitum. Additionally, this is done with no statistical evidence to suggest all the added “safety features” would save lives… we add layer upon layer with decreasing or non-existent marginal returns.

The EMS community is no better. They need twin engine helicopters. No, they need twin engine, IFR helicopters, perhaps with two pilots – just to be safe. In fact, let’s wear helmets, Nomex™ flight suits (you know, in case there’s a fire)… and what about boots and gloves? Is the helicopter safe? Sure, put your son or daughter on the gurney with cotton sheets while the “Rambo” crew helps you! Think, would you get on an airplane where the pilot and co-pilot wore a parachute?

Meanwhile, look at the checklist for a helicopter and compare it to a commercial jetliner. The 150+ passenger jetliner has all their checklists on one page. Meanwhile the average helicopter is not so lucky. We turn things on, turn things off, check electric systems, hydraulic systems, back-up systems, and brief countless items. It’s not a matter of what we do; it’s a matter of how much we do.

An MD-80 splashes into the Pacific (at probably greater than 200K) and the people are using their seat cushions for flotation, yet the helicopter community performs 2.6 million take-off’s and landings in the Gulf of Mexico and doesn’t feel safe unless we have 6 layers of protection. That’s because we believe systems can protect us from our own human nature. The effort is praiseworthy, though ill-advised. Certainly one might want to extrapolate my assertion to preclude any manner of safety procedure – that is far from my point; Let the reader understand, this is an argument of degrees. My question is, “When will we say, enough is enough?”

People make mistakes and we need to address them when they occur on an individual basis, to focus on the crewman when necessary rather than seeking a system solution for all mishaps. You see, if the pilot lands with the gear up, installing a bigger gear handle may not be the real solution. If an aircraft crashes in the North Sea, wearing a better survival suit may not have made any difference to those in the aircraft.

Let’s allow realism to touch our industry. Certainly make the aircraft safer, train the people – let’s just stop our knee-jerk, unrealistic, layering of solutions to non-existent problems.


 

Posted in: Safety

Comments

Mike King
# Mike King
Tuesday, February 23, 2010 10:59 PM
I recently used this article as the basis of a collage article critique assignment, i thought i would share it with the group.


The author argues that not all aviation accidents are preventable. Furthermore, since the majority of accidents contain a component of humor error as a contributing factor, individual responsibility should be emphasized rather than “blanket” changes.

As a senior Army aviator and OSHA certified Army safety officer, I fully agree with the author’s opinion. After twenty years in Army Aviation I have witnessed the death of personal responsibility in favor of “knee jerk” reactions and blanket policies. The resulting actions have little effect on reducing accident rates, and only increase pilot workload and frustration levels.

In his editorial the author did not site statistics or disputable facts, however he did include several examples addressing multiple aspects of the aviation community.

The author correctly defines an accident as an “unplanned event” and states that “the very existence of accidents is demonstrative of the predisposition of the human condition, namely our own imperfections.” Therefore, each accident should be evaluated so that the corrective actions are tailored to the specific event leading to the accident. In some cases this may lead to a systemic change, but the majority of cases will result in addressing an individual failure. Too often however, it is a blanket change, a “new policy” that is instituted as a hasty reaction to an individual or isolated error.
The goal in aviation is to mitigate all risks to the lowest possible, acceptable level. Once achieved what remains is “acceptable risk”; the level of risk that one is willing to accept in order to achieve a goal or complete a mission. This is no different in any aspect of our daily lives. Crossing the street is dangerous. We mitigate the risk by crossing at crosswalks and looking by ways before crossing. However at some point we must concede that we have done all that we can reasonable do, and which point what remains is acceptable risk. And we cross the street…

The author repeatedly states that in no way is he advocating abandoning the pursuit of accident reduction measures. His argument is that systemic changes applied to all mishaps do not address the individual failures. If we as a community addressed training deficiencies and held pilots personally responsible we would do more to reduce our accident rate and improve the quality of our pilots at the same time.

You can mitigate all risks, but you can't mitigate all risk. “How we respond to our imperfections is what improves our condition.”




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