“We’re Doomed, I Say, Doomed!”
Posted June 1, 2012
For the next two paragraphs, you’re a member of a mishap-investigation board. Assess this finding: “On the last ski run of the day, he fell and broke his leg. No specific personnel errors.” Do you buy it?
Or these two: “Broken leg while on dirt bike—member was wearing all proper safety equipment and abiding by the safety regulations.” “Fractured right hand. Accident couldn't be avoided.”
The apparently doomed trio included an SKC in Japan (three days in the hospital and another five days off work), an E-5 from a fighter squadron (a day in a hospital and a month of LIMDU), and an AD1 from a patrol squadron (five weeks of LIMDU).
Assuming you swallow the inevitability of these three mishaps, one question remains: How does anyone survive these activities, if there are no precautions or if precautions are futile?
I’ve fallen down while skiing plenty of times. The causes were clear: I was inexperienced, tired, and/or exceeding my abilities (one time I mistakenly skied down a slope that was closed due to icing). I’ve engaged in PT about five thousand times, and my only hand injury was in a bike wreck that was my fault.
I think the “accident couldn’t be avoided” approach to mishaps is sloppy and lazy. If you don’t think a particular kind of mishap is preventable, you probably aren’t going to try to keep it from happening.
Here’s the best example I know (you are now transitioning from mishap investigator to time traveler). We’re going back to a night in 1953, when a Navy transport crashed at an air station in Florida, killing 44 people. The initial accident report listed the cause as "undetermined." This opinion raised the hackles of the top brass to such an extent that they launched a full-blown, unprecedented, no-holds-barred study, uncovering numerous glaring deficiencies. For one thing, the pilots had so little night-flying experience that they were arguably unfit for the mission.
This mishap stood out only because it killed so many people. In FY53, five percent of all Navy aircraft were destroyed in mishaps, and 423 Navy aviation personnel died in smoking holes.
Of the 2,266 major mishaps, investigators believed that 22% were avoidable. More than 1,400 mishaps were attributed to errors of the pilot; three-quarters were "errors in judgment and technique." Yet, according to the thinking of the times, these mishaps weren’t "avoidable."
In retrospect, they were obviously avoidable. In FY11, there were nine Navy aviation Class A mishaps and two fatalities. It wasn’t because we now magically have a bunch of luckier pilots and mechs.
OK, so we don’t live in the 1950s, and there were a lot more preventable mishaps back then. Where are we now? At least we have a much better definition of “preventable mishap”: one in which the risks were known in advance but weren’t controlled. The mishaps weren’t brand new, unheard of or unexpected (not that anyone “expects” to get in a mishap, but that is a whole other problem).
Today’s preventable mishaps seem easily preventable, at least in terms of the physical difficulty of the action that would have been necessary. It isn’t hard to call a cab when you’ve been out drinking and have to get back home or to the ship. It isn’t hard to stop for a cup of coffee or a soda and a chance to stretch your legs when you get drowsy. It isn’t hard to ease off the accelerator. The problem is a host of familiar (and potent) human factors, including deeply ingrained bad habits, misplaced optimism, complacency, and artificial, self-imposed urgency.
Here’s another current mishap report. A starter on a light shorted out, so a Sailor had to change it. She “took all proper precautions,” the report said, but still got shocked. “This shock was not preventable,” the report alleged. Really? Do you think that circuit was tagged out?
An aviation warfare systems operator first class lost control of his motorcycle on a curve in Pennsylvania. He broke a bunch of bones (including his back), spent 13 days in a hospital, nine months off work, and four months on light duty. “All precautions were followed,” the report said. Can that possibly be true? Are motorcycles intrinsically unable to go around curves? If so, how do so many riders do it so often?
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