Premium on Safety - Issue 46, 2022 - 2

A MESSAGE FROM USAIG
Accident Case Study: Just a Short Flight
TAKE A SECOND LOOK
Have you ever reread a book and
been surprised at what you missed
the first time? I experienced that
recently when a project steered me
back to an accident report I first
read when it was released a few
years ago. Aviation tends to orient
us toward technical issues. That can
occasionally make you overlook
important things.
We're eager to know which component failed after an
incident or trace the series of erroneous or inadequate decisions
and actions by the crew. Does our aircraft have that component?
Could we see ourselves ever going down the same path? Those
questions can lead to tidy and quick interventions: inspect similar
hardware, study to address a knowledge gap, adjust a checklist
or SOP. Perhaps we conclude our operation is dissimilar enough
from the accident situation that we're already immune. However
we get there, once we feel insulated from a similar hazard
sequence tripping us up, we move on.
The report I looked back on was for the May 2017 loss of a
Learjet on approach to Teterboro. The accident has had wide
coverage in safety forums. It's laden with examples of inadequate
planning, unprofessional cockpit environment, lost situational
awareness, continuing an unstable approach and, eventually,
loss of control. I saw those things as the whole story the first time
On May 15, 2017, a Learjet 35A crashed while circling to land in
visual conditions at Teterboro Airport in New Jersey. The AOPA
Air Safety Institute examines the links in the accident chain and
lessons learned from a flight gone wrong.
around. That's easy to do and, because some of the pilots'
misdeeds are egregious, it's similarly easy to conclude those pilots
were just 'outlier unprofessional' and there's not much actionable
here. But this time, several more foundational and organizational
questions beyond the cockpit and that specific crew started
grabbing my attention.
The operator was short staffed. The director of ops was the
acting safety manager. Did bodies-to-scheduling pressure help
enable a rationale that any PIC + any SIC makes a crew-without
deeper consideration of whether known attributes of each made
the pairing safe and sensible? A progressive qualification policy
should have prohibited the SIC from being the pilot flying, yet he
was at the controls until seconds before the crash. It also specified
that SICs would be paired with a check airman periodically to
gain flying experience. With no check airman on staff for some
time, the only way for SICs to gain any at-the-controls time was
for PICs to bend the rule and let them fly. Is that partly what drove
the SIC to have secured alternate employment (he had not yet
told his employer at the time of the accident)?
The report relates many unprofessional aspects of the PIC's
conduct. Could stressors have helped steer him outside his norms?
A bare bones company CRM training program, an unspoken
mandate to defy policy to get SICs flying time and being
assigned (sans leadership training) to operate with a fellow pilot
needing mentoring may have left the PIC overburdened and
unready for his task. It was lost on me the first time through, but
2
the NTSB concluded from the cockpit voice transcript that the
PIC was distracted by his extensive attempts to coach the SIC on
basic flying skills, interfering with normal division of cockpit duties
and degrading the crew's overall performance. Despite the PIC's
misdeeds, the NTSB documented persistent efforts on his last trip
to do something he was tacitly expected by his employer to do
without any meaningful training, to his and the flight's detriment.
There are things in this and every accident report that raise
questions beyond the technical issues we tend to seize first. The
aspects I missed the first time through point to subtle dynamics
that could be lurking in almost any work setting. I hope you take
second looks (or more) at the circumstances and events that
hold lessons that need seeing. It's an invaluable practice to keep
advancing your safety culture and organizational excellence.
Stay well, fly smart, and fly safe.
Paul Ratté
Director of Aviation Safety Programs, USAIG
https://youtu.be/BML2lfqaK-4
Premium on Safety - Issue 46, 2022

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