Monday, August 12, 2019

The Reason Pilot Error Root Cause Doesn’t Exist

The Reason Pilot Error Root Cause Doesn’t Exist
By Catalina9

Pilot error root cause is a simple way to identify the root cause off an incident. There is no root cause analysis required, there is no risk assessment required and there is no need for solutions. Anyone can come up with the pilot error root cause. Over the years, pilot error was the standard root cause and it still is in many organizations, large or small.

The cube on the left is a definition of pilot error.

Reading newspapers, the general public seems to be a firm believer in pilot error as root cause and after every incident, major or minor, there is an outcry for more regulations. The other day a small training airplane crashed, and the community is looking for someone to blame. Finding someone to blame is simple, but there is a simple reason why it doesn’t work and why it cannot be a root cause: Pilot error is the messenger of the root cause and often it is the messenger who is blamed for the event.

Let’s apply taxiing as an example to analyze pilot error as root cause. On the ramp there is a taxilane for the pilot to follow. This taxilane provides for 100 feet wingtip clearance to any fixed obstructions on each side. There is no policy in place for wingtip clearance. One day there is an aircraft parked on the ramp and the pilot move to one side to clear the airplane. In the moment of estimating the wingtip clearance to the parked airplane, the pilot strikes a building with the other wing. The pilot gets fired with a note that the pilot is a high-risk pilot, accident-prone and that the airline expects better from its pilots. The root cause finding was pilot error. Since there were no wingtip clearance policy in place, the airline could not reference a policy for punishment and chose to apply an expectation that it’s common sense not to hit a building. Management feels good about themselves and proudly notifies their customer that the root cause was pilot error and the pilot was therefor fired. The customer is thrilled that the airline could establish the root cause within hours and take action.   

The 5-W’s is to ask why there are no digital instruments.

The company applied the 5-W’s root cause analysis and answered five times that the pilot failed or did not do something. Answers to the 5-W’s were that the pilot did not look, the pilot did not stop, the pilot did not turn away from the building, the pilot did not ensure enough clearance and the pilot did not apply common sense. When they did a risk assessment, they found that the pilot was accident-prone and a high-risk pilot. What the pilot did while taxiing was not of any concerns to flight operations or safety. The problem was solved. However, to be on the safe side, the airline implemented a safety policy stating that a pilot shall not taxi closer than 5 feet to a fixed or mobile object.

As several months went by without any more wing-strikes, the safety department concluded that their 5-foot wing clearance policy was working as intended and the file was closed.

A year after the first wing-strike there was another event at the airport and airplanes were parked on the ramp. Again, there was another wing-strike. Again, management sited the root cause as pilot error and failure to maintain at least 5 feet wing-clearance. The pilot was fired, and the SMS report was closed. To be on the safe side, the policy was amended to a 15-foot wingtip clearance to fixed or mobile objects. The SMS policy was amended and now they were certain that there would not be any more wing-strikes. However, the following year, with a 15-foot wing clearance there was another strike.

Pilot error, or human error is not a root cause, no matter how much a manager wishes to point the blame on a person within the organization. Pilot error is a symptom of incomplete support. The simple reason is in the answers of the 5-W’s root cause analysis. For pilot error to be the root cause the answers must be that the pilot failed to do a task, or that the pilot did not do a task. A pilot-error root cause finding is incapable of answering what the pilot did.

The expectation is to answer correct distance between the row of trees
Establishing a 5-foot or 15-foot wingtip clearance policy is irrelevant to forward looking incident avoidance. The sole purpose of establishing this policy is to have a tool to point blame when there is an incident. If the 15-foot wingtip clearance policy was a true reflection of management’s position to ensure that no airplane is taxiing closer than 15 feet, they would be required to have a precision measuring tool available in the aircraft for the pilot to read out the distance. There was no measuring tool installed in the airplane, and no taxilane was painted as guidance for the pilot while taxiing. The management of this organization did not monitor a 15-foot wingtip clearance but applied punitive actions for the wing-strike.

Anytime one of the hundreds of airplanes, at any global location, an airline establishing a 1-foot, 5-foot, 15-foot clearance, or a 100-foot wingtip clearance has no other choice but to monitor taxiing every single time an aircraft is taxiing. The policy is not just applicable to the ramp, but also to the taxiway and runway. The purpose of this policy is not to prevent wing-strikes, but as stated, to ensure a specific minimum distance is maintained.

A pilot-error root cause is simple to apply, but extremely complex to manage. A pilot-error root cause becomes unmanageable for any size organization. If pilot-error was a true root cause, it would not take over 100 years for the root cause to be corrected. 

A root-cause analysis is first to backtrack the process in time, space and compass from the point of impact to the fork in the road where the events of time, space and compass join. When this is established, a root cause analysis can begin. With a proven root-cause analysis method, it becomes impossible to define the root cause as pilot error and accident-prone pilots. The simple reason that a pilot-error root cause doesn’t exist is that it is impossible to analyze a negative of what did not happen prior to the incident.  


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