Sunday, January 22, 2017

Approach, We Need to Divert

Being a good pilot means always having a backup plan. I don't care if you are a VFR-only pilot on an afternoon outing or pushing back in a twin aisle airliner for an overseas leg. The very nature of aviation means that things will never go exactly as you planned, and sometimes not even close to how you planned. 

This means you need a backup plan. What happens if you have a mechanical? How will you react if it happens on takeoff? What if you don't break out on the approach? How about if your alternate weather goes down enroute? All these questions should be in the back of your mind before and during your flight. Then, should something happen that you didn't anticipate, reacting to it is a simple matter of implementing your backup plan rather than having to take the time to come up with a new plan.

LaGuardia to Midway

We were scheduled for the first day of a three day trip to fly a round trip from Chicago's Midway Airport to New York's LaGuardia and then back east to Newark's Liberty Airport for the overnight. The trip from Chicago to New York had been uneventful and we even landed early due to a strong tailwind of about 100 knots.

The departure weather at LaGuardia was VFR and we departed at about 1705 local (2205Z) without much delay at all, which was especially good for any New York airport. The forecast for Midway, issued at 1729Z was IFR with low ceilings and visibilities forecast:

TAF KMDW 161729Z 1618/1718 10006KT 1SM -SHRA BR OVC004 FM170100 10012KT 1SM SHRA BR OVC003 TEMPO 1703/1705 1/2SM TSRA FG OVC003CB FM170600 VRB03KT3/4SM -RADZ BR OVC003 TEMPO 1706/1710 1/2SM FG FM171300 24010KT 2SM BR VCSHOVC005 FM171600 27008KT P6SM VCSH OVC006=

A quick translation of this forecast shows that the visibility was forecast to be one mile with rain showers and a ceiling of 400 ft for our arrival. 

Even though there was a "TEMPO"  or "temporary conditions" line in the forecast for 1/2 mile visibilities, this was not due to happen until 0300Z on the 17th, or a few hours after our arrival. Chicago is six hours behind Zulu (GMT) time which means Zulu midnight is at 6:00 PM in Chicago. We were, however, still required to have an alternate, and had Louisville (SDF) declared on our release.

Midway has five runways forming a cross pattern but only two strips of pavement are suitable for air carrier operations, 31C/13C and 22L/04R. They were landing runway 4R for our arrival. That runway is served by an ILS with minimums of 5000 ft. or 1 mile. 

The METAR, or current observation for our arrival showed a 300 ft. ceiling with a visibility of 6000 ft. Piece of cake, we thought. The decision altitude (DA) for our runway was 250 ft. height above touchdown (HAT) and the visibility was a good 2000 ft. above what we needed. 

METAR KMDW 162253Z 09006KT 1SM R31C/P6000FT -RA BR OVC003 02/02 A3005 RMK AO2 SLP184 P0001 T00220017=

This translates as prevailing visibility of one mile with a specific runway visibility of 6000 ft and a ceiling of 300 feet.

My first officer was flying the approach and was highly experienced, so I had no reservations about letting him fly this approach. So as we were being vectored to final, we heard approach mention that the visibility was being reported as 4500 ft. I then said that we needed 5000 ft. to begin the approach after which approach quickly revised the report. We were alerted though to expect an approach right to minimums.

The next thing we heard after switching to tower was the aircraft in front of us announcing a go-around. Now we really knew that it would be close. An old technique of mine is to run my chair forward so as to be able to see over the nose. If we could pick up approach or runway lights, we'd be cleared to descend for landing and doing this helps. One small problem is that runway 4R at Midway has no approach lights, only runway end identifier lights and a precision approach path indicator (PAPI). Great.

Go Around!

Well, we got down to minimums and I announced "minimums". There was nothing in sight at all. My first officer announced "go-around", hit the takeoff/go around (TOGA) button, pushed the throttles up, and around we went. Here is where it got busy.

We get the airplane away from the ground, cleaned up and on a downwind vector and then we have some decisions to make. Is the weather persistently bad or was that just a passing cloud? Do we have gas for another try? Is my declared alternate the best choice and what's the weather there?

Right away I saw that the first question was moot because we didn't have enough gas for another try. I had just under 8000 lbs., and the burn to my alternate, Louisville, was about 3000 lbs., enough to get us there comfortably, but none to try again. So on downwind we told approach that we needed to divert. They gave us a climb and handed us off to center. Center gave us a vector direct to Louisville, which was VFR.

Louisville may seem like a rather distant alternate, but there was most likely some method to their madness when dispatch filed this flight plan. When a busy hub airport like Midway goes below minimums, chaos breaks out everywhere. Dozens of airplanes might be looking for alternates at the same time. One of the closest and most obvious alternates is Indianapolis, but they can be quickly overwhelmed with diverting airplanes in a short amount of time. So dispatch tries to spread out the pain of multiple diversions to other airports depending on the weather. Tonight Louisville and Milwaukee drew the short straws.

Get In Line

The approach and landing in Louisville were normal. We were then directed to an unused runway where we sat until there was a gate available. All the gates were full and there was one airplane in line in front of us, so we waited for about an hour until we could park. The agent already had our paperwork for the trip back to Chicago. The weather had come up some and should’ve been good for our return. Midway was now landing on runway 31C which had a 4000 ft. minimum visibility as well.

We signed the release, got our gas, and pushed back. The flight back to Chicago was also uneventful, at least until we got to minimums on the ILS to 31C. It was now my leg. We briefed and flew the approach pretty much the same way we had a few hours earlier. When my first officer says "minimums", I didn't see anything. I thought "here we go again". Just as I start to push the throttles up for our second go-around of the evening, I saw the runway. I pulled the throttles back and we landed well within the landing zone and taxied to the gate.

Pulled (and Paid)

All in a day's work, right? Now we’ve got maybe 30 minutes to find some dinner and to get the airplane turned around for our delayed, but final leg of the evening to Newark. As I step out into the jet way, I see a pilot friend of mine. I ask him if he's deadheading to Newark but he says no, he's working the flight. I said that can't be because I'm working the flight. A quick check of the paperwork shows that indeed, he is flying the next leg. So I go back to the cockpit to gather my gear and then check the computer when I'm back in the terminal.

Sure enough, I've been tagged by Part 117, our new flight time regulation. With all the excitement, I've racked up seven hours and eighteen minutes of block time. With the Newark leg forecast to be about two hours, this put me over the maximum flight hours by about 20 minutes, hence I was illegal to operate the flight. Scheduling was nice enough to find me a hotel room in Chicago thus saving me a rain-soaked trek to my crash pad. It is honestly the little things that count.

Be Ready

The next day I am rerouted to a different city than my originally planned trip but it pays the same so there's no harm. All in all, it was just another routine divert and reposition. And the reason that I use the word "routine" is because I was ready for the weather to go down. Diverting is a headache, sure, but at no point was I "uncomfortable" with how things were happening.

We were both well trained and prepared, and were flying a well-functioning and reliable airplane. Things won't always go how you might have planned, but that is never any reason to be caught by surprise.

Captain Rob Graves is a veteran airline pilot and retired Air Force officer. He currently flies a Boeing 737 for a major American airline where he has over 25 years of experience. His Air Force career included flying the T-37 primary trainer, the KC-135 Stratotanker, and the C-5 Galaxy cargo aircraft for worldwide operations. He is the author of This is Your Captain Speaking, an aviation blog. It can be found at He also writes

Thursday, January 19, 2017

Then There Was the Time I Saw a C-5 Do the Splits

C-5 Galaxy does the splits
The airplane and the landing gear wanted to go different directions.

The C-5 Galaxy is a magnificent airplane. I flew this amazing machine for over a decade and many thousands of hours between the years of 1991 and 2003 while a member of the 312th Airlift Squadron at Travis AFB near San Francisco. And while the airplane has some amazing capabilities, she would occasionally break in really creative ways. What follows is the story of one of those times.

The grandiosity of this airplane is difficult to convey in both word and picture; she must be seen in person to be fully believed. I still recall my first flight aboard a C-5 as a student at Altus AFB. It was difficult to get my head around the thought that the thing actually moved when we taxied out of parking, let alone flew. And yet fly she did.

She was a pleasure to fly. One of the design engineers at Lockheed must have at some point taken his father's Cadillac Brougham out for a joyride because that is an apt description of her ride. She was big, but with full time three axis flight augmentation, she was lighter on the controls than a 737. She was equally agile on the ground with the ability to execute a 180 degree turn on a 150 foot wide runway (using 147 feet, according to the flight manual). This fun fact ties in to our story.

The Elegance of Simplicity Never Applied to the C-5

The size of this aircraft presented many new and unique challenges to her builders, the Lockheed Corporation. As an aside, the Boeing Corporation, losers of the original competition to build the CX-HLS heavy lifter back in the sixties, went on to use the resources gathered for that project to build the 747. Lockheed, the winner of the contract, was faced with the problem of creating a drive on drive off airlifter with a footprint capable of operations on soft field forward operating locations.

The solution was to employ four main landing gear accommodating six tires each for a total of 24 main landing gear tires. A four tire nose gear brought the total to 28. Spreading the maximum 840,000 lb. weight of the aircraft over 28 tires was expected to allow operations on fields having less weight bearing capacity or thinner pavement. It wouldn't break up the concrete or sink into the mud. C-5s even land on ice in Antarctica due to this soft footprint.

The four landing gear however, arranged in a tandem, or two by two, presented another problem: turning. Getting the airplane turned around in as short a radius as possible meant that the gear would scrub furiously in the turn. Anyone who's ever pulled a tandem wheel trailer around a tight corner has experienced this. The solution is the same as that used on those large carts at your local big box store. Just make the rear wheels caster or turn.

So that is how the airplane was designed. When going into a turn, the pilot in the left seat would throw a switch on the center console which released hydraulic pressure from the rear main gear allowing them to caster like a shopping cart wheel. When steering out of a turn, he or she would then return the switch which would apply pressure to drive the gear back into alignment. The copilot was charged with keeping an eye on gauges indicating the caster angle to ensure the gear were powering back to their aligned position when coming out of the turn. Rube Goldberg would have been proud.

The Ghost in This Machine is Named Murphy

The date was July 8, 1999 and the place was Kadena Air Base, Okinawa, Japan. We were on a WestPac "channel" mission. That meant a routine five or six day jaunt around the Pacific Rim moving opportunistic cargo and household baggage from reassigned military families. The purpose of this type of mission was ostensibly for training, so what was carried was not of real import. Many times, in fact, there might be a FedEx or UPS plane shadowing our route carrying stuff that was actually important. The C-5 was voluminous, but alas not too reliable as we shall see.

Though I don't recall exact numbers, we probably had a cabin load of perhaps 150,000 lbs. and a fuel load of perhaps 225,000 lbs. for a takeoff gross weight of about 750,000 lbs. Our destination was Elmendorf AFB in Anchorage, Alaska, a distance of 4400 miles, so we were somewhat heavy. It was an entirely routine mission planned for perhaps eight or nine hours depending on the winds.

I was in the jump seat for takeoff as we were an augmented crew with three pilots. Being augmented meant that our crew duty day could be stretched to 24 hours if need be. Engine start was normal as was taxi out of parking down the parallel taxiway. It was on the turn from the parallel taxiway and onto the hammerhead that we encountered a bit of bother.

As per normal, when the pilot started the turn, he reached over and flipped the red guarded caster power-back switch to the caster position and stated "caster" on the interphone. And as we came out of the turn, the pilot returned the switch to its original position which should have driven the gear back into alignment.

This didn't happen. Coming out of the turn, the airplane chugged a little bit and came to a halt. What this normally meant was that one of the gear lagged a bit while powering back to the center position. And sure enough, that is what the right rear gear indicator showed. It was out of alignment by perhaps 20 degrees.

This meant that the gear did not automatically return to alignment. The approved fix was to roll the airplane forward a bit while the copilot manually commanded the gear to center using the manual power-back switches. The airplane had to be moving for this to work. So that's what we did...or tried to do.

At first the airplane wouldn't move, so the only solution which presented itself was to add more power. A lot more power. The pilot pushed up the throttles further and eventually the airplane did move, but not willingly. She was bucking like a bronco and the errant gear was still not moving to center.

After about as much of this as we could stand, we stopped the airplane and deplaned one of our engineers to take a look. What we heard next on the interphone told us that something was amiss. "Holy $#!%...You have GOT to see this!!" or something to that effect. It was at this point that we realized that we were probably not going to go flying that day.

How Did It Get Like That?

The engines were shut down, maintenance was called, and I climbed down the two stories from the cockpit to take a look myself. What I saw amazed me and reinforced my belief that Lockheed built one tough airplane.

The reason the airplane didn't want to roll was not because the gear had failed to return to center. It had. But it hadn't stopped at the center position. A failure of the caster power-back valve allowed the gear to not only center from the left but to keep on going in the opposite direction to the right. The airplane was trying to roll straight ahead but the right rear gear wanted to go right and was being drug. There were thick black rubber marks trailing behind as it was drug at a sideways angle while supporting over 100,000 lbs. of weight.

But the most remarkable sight was that of the gear strut. This piece of metal which supports the six tire gear truck is perhaps several feet in diameter, and it was bent at a very unmistakable angle away from its partner on the front gear. I was amazed that the supporting structure had even held together as it must have been under thousands of pounds of sideways pressure. It seemed a sure bet that some sort of internal damage must have occurred.

Well, the maintenance guys disagreed. Apparently this was no big deal, at least from a structural point of view. The fix was even easier. The C-5 has the capability to "kneel" down which means it can be lowered on its struts so vehicles can drive on and off. What is even more convenient is that each individual gear truck can be "kneeled" by itself meaning that it will lift off the ground while the other three main gear support the aircraft. Very handy for tire changes.

So the maintenance guys merely kneeled the errant gear as the entire airplane creaked and groaned while coming back into alignment. The bad valve was replaced, and the next day we were on our way back home with the added bonus of an extra day on beautiful tropical Okinawa, and an extra day of per diem to boot!

The author in front of the stricken plane.

Thursday, January 12, 2017

Captain's Authority, Captain's Responsibility

airline captains' authority has eroded
Should he run the entire show?

A recent incident on a JetBlue airplane where former Senator Al D'Amato was removed from the flight after causing a disturbance got me thinking about captain's authority. In this incident, some passengers needed to be relocated due to a weight and balance issue. When some of the passengers refused, Senator D'Amato apparently started a ruckus and blamed the captain stating "the captain needs to grow some balls", according to another passenger.

My first thought upon hearing this story was wondering why the captain allowed himself to become involved in a passenger dispute in the first place. That's almost always a no-win situation. Then I thought that Al D'amato is in his late 70s and probably still entertains the quaint notion that airline captains actually run the show.

In one sense they still do, but it is an extremely narrow writ. Federal regulations give airline captains absolute authority over everyone on a commercial airliner but only as it pertains to the safe conduct of the flight after departure. As the flight was still parked at the gate, the captain had no legal authority to order anyone to do anything, and my guess is that JetBlue policy states that pilots are not charged with moving customers. That is a customer service issue to be handled by customer service specialists.

And in case there is any doubt about that, pilots who still have old school ideas about injecting themselves into customer disputes can quickly find themselves with a few weeks of unpaid leave. I've seen it happen time and again. That, unfortunately, is the new reality of today's airline operations. Cost a guy a half a month's pay and he should eventually get the idea.

My guess is that the pilot was attempting to persuade some customers to voluntarily move, but I find it highly unlikely that he was empowered by JetBlue to order anyone to move. And I of course don't blame passengers who took the effort to get to the airport early to get in the first boarding group now being asked to sit in the back of the bus.

So what are your thoughts? Should we return to the old school days where pilots actually did run the whole show, or should they just stick to the mechanics of flying the plane as they are expected to today?

Thursday, January 05, 2017

I Feel Ok, But I Still Called in Sick

Flight doctors keep pilots flying
A visit to the flight doc might prevent this 

To be fair, I really do have a bit of a cold. It started the day before my trip with some sneezing and a headache. It's really nothing most workers would consider staying home for. A daytime Theraflu has got me feeling almost fine, but I still didn't go to work. Instead, I called scheduling to get myself pulled off my trip and replaced. Now I've got some extra time to write a blog post. Am I lazy or is this a good call?

You Don't Want Me Flying Your Plane

Though it may sound like I'm milking the system, trust me when I say that you do not want me anywhere near your airplane for a number of reasons. The first, obviously, is that I'm not 100%. Flying places enough physiological stress on a body as it is. Disrupted circadian rhythms, fatigue, dodgy airport food, and dehydration from hours in dry airplane air can all contribute to a degradation of the alertness which is needed to operate an airliner.

Throw in additional stressors such as congestion, or a headache and effectiveness in the cockpit can drop precipitously. My experience has been that no matter how you feel while sitting in your kitchen, you will always feel worse on an airplane, medically speaking. A bit of an itchy nose is guaranteed to become a non-stop sneezing fit on the airplane. So if I'm feeling a bit off at home, I don't go in. 

Almost as important as the underlying illness, the drugs taken to combat the symptoms of a cold or flu are themselves disqualifying for operating a commercial airliner. The FAA does not publish a list of medicines which pilots are allowed to take while operating an airliner, but would rather have each individual pilot with a medical complaint be evaluated by a doctor. Then a determination should be made as to whether the pilot should be flying with that medication. Some common ones are approved, while others are not.

For simple ailments such as a cold or the flu, pilots are expected to remove themselves from flying until they feel fit to fly. As far as the over the counter drugs for a cold are concerned, the FAA recommends a wait of five times the recommended dosing interval. This means that if the directions suggest a certain dose of say every six hours, a pilot should wait five times that, or 30 hours before operating an aircraft.

Pilots and Doctors: An Uneasy Relationship

All pilots, whether civilian or military, need the approval of a doctor to be able to fly. But because doctors can ground pilots, this means that pilots are never too comfortable around doctors. Airline copilots or first officers in the US are required to get an annual FAA Class II medical exam. Captains and international pilots need to have an FAA Class I medical exam every six months. All airline pilots require a Class I medical after age 60 and an electrocardiogram is required annually after age 40. 

The idea here is to catch any sort of medical problem before it manifests itself while the pilot is behind the controls. If something should be found that is disqualifying, such as say complete color blindness, there isn't much that a pilot can do. For many other ailments, however, a pilot can appeal their case to the FAA's Office of Aerospace Medicine for the issuance of a waiver, otherwise known as a Special Issuance.

In this case, a pilot would be able to continue to fly using a "Statement of Demonstrated Ability" which means that whatever ailment they have is considered to be static or non progressive. In plain speak this means it is not getting worse nor affecting the ability to fly.

The unease which pilots have around doctors stems from the perception of misaligned incentives. If something during a flight physical is found to be in a grey area, the pilot will naturally want to keep flying, while the doctor would rather err on the side of keeping the pilot grounded. There is good reason for this as the doctor could be held responsible for missing something which causes trouble later. Here's the text from the FAA's guide for aviation medical examiners (AMEs):

The consequences of a negligent or wrongful certification, which would permit an unqualified person to take the controls of an aircraft, can be serious for the public, for the Government, and for the Examiner. If the examination is cursory and the Examiner fails to find a disqualifying defect that should have been discovered in the course of a thorough and careful examination, a safety hazard may be created and the Examiner may bear the responsibility for the results of such action.

So of course this makes pilots naturally wary about reporting every little ache and pain during their flight physical. They don't want to lose their livelihood for what they might perceive as overreach on the part of an overly cautious doctor. Pilots also tend toward stoicism as a general rule, so keeping quite about a random ache, especially when it might ground them, suits them just fine.

A Flight Doc and a Real Doc

Most aviation medical examiners, or flight docs, do not work for the FAA. They are usually physicians in private practice who have volunteered and are designated and trained by the FAA to perform flight physicals. It seems to be a somewhat lucrative practice as the physical itself usually takes about a half hour with about ten minutes of that time actually being spent with the doctor. The cost is around $150 cash as many AMEs do not take insurance. I even know of some AMEs who have shut their general medicine practices and now perform only FAA physicals.

Of course it is now generally recognized that avoiding the doctor is not really a good long term health care strategy. Pilots (begrudgingly) accept this as well, but rather than confessing all their health issues to their AME, they engage another or "real" doctor to check things that aren't included in the FAA medical exam. This might include things like a prostate exam or perhaps a closer look at a discolored mole. 

Truth be told, the AMEs I've seen over the years have never seemed too thrilled to have these sorts of ancillary medical issues raised in an FAA examination. The idea is to check the things on the FAA list, collect their fee, and usher in the next pilot. They get it. Should a complaint which is ancillary to the flight physical be investigated and found to be nothing by the non-FAA doc, all the paperwork of having to deal with the FAA bureaucracy is also conveniently avoided. In fact, in the competition between AMEs, the word quickly gets out on the street about which docs just check the essentials and which ones are "tougher".

So do I mean to suggest that pilots or flight docs are somehow "cheating" the system? Absolutely not. Should a serious issue be found by a non-FAA doc, pilots are legally obligated to inform their AMEs of all medical care other than routine physicals, so even the FAA recognizes that their own exams are not all encompassing. It is the false alarms and paperwork that are being bypassed.

Went Peacefully

There's an old aviation joke that goes: "When it's my turn to go, I want to go out peacefully in my sleep like ol' Joe...not screaming in terror like his passengers".

Yes, macabre, but there have been a number of times that a pilot has died at the controls. The latest incident happened just over a year ago when the 57 year old captain of an American A-320 died while enroute from Phoenix to Boston. The pilot had had bypass surgery years earlier and likely suffered a heart attack even though he had been flying for years after the surgery. The first officer landed the plane without incident.

Keep 'em Flying

So even though there exists some measure of disaffection between pilots and doctors, I believe the system functions well to ensure that only healthy pilots are at the controls. For those pilots who end up with serious health issues such as heart problems, or cancer, the bureaucratic wheels at the FAA can turn slowly, but they do eventually turn and many pilots who have suffered these types of problems can get back into the cockpit once their problems have resolved. 

Flying airplanes demands complete attention from alert and healthy pilots. With all the negative physiological stresses on members of this profession, having someone keep an eye on the pilot's health while he or she keeps an eye on your airplane maintains the high integrity and safety of today's aviation system.

Monday, January 02, 2017

Don't Depend on the Kicker to Win the Game

LaMia 2933
If it routinely comes down to the kicker to win, the team has failed.

Last month I wrote about the crash of LaMia 2933 which resulted from fuel starvation. Post crash investigation revealed that the flight was planned beyond the range limits for the aircraft and no provisions were made for required reserve fuel. Thus, after encountering a slight delay for another aircraft, the LaMia airliner ran out of fuel and crashed killing 71 of the 77 passengers and crew aboard the aircraft.

Much opprobrium has (rightly) been placed upon the heads of the pilots who planned the trip to exceed the capabilities of the aircraft they were flying, but I'd like to take a closer look at the circumstances of the situation to try to understand why the pilots would make such a foolish mistake. It certainly wasn't made in a vacuum.

Cinderella Story

The trip was a charter flight for the staff and players of the Brazilian Chapecoense futbol squad along with some journalists to the Copa Sudamericana Finals in Medellín. They were scheduled to play against Atlético Nacional the day after their arrival in Medellin.

Chapecoense was the first Brazilian football team to make it to the final of the Copa Sudamericana finals in three years. Representing a city of about 200,000 in the state of Santa Catarina, Chapecoense had bested more highly favored teams to represent Brazil in the finals match. Thus, there was intense interest in the match including a significant amount of national pride.

Chapecoense had wished to charter LaMia to transport the team directly from Sao Paolo to Medellin but were prevented from doing so by international regulations. Any charter aircraft flying between Brazil and Colombia would have to be registered in one of those countries. LaMia, however was a Bolivian registered operator, so provisions were made to fly the team on a Bolivian commercial airline to Santa Cruz in Bolivia before transferring to LaMia for the leg to Medellin.

A delayed departure from Santa Cruz meant that a planned refueling stop in the Bolivian city of Cobija was not available as that airport closed at sunset due to lack of runway lighting. The LaMia pilot then filed a flight plan showing a refueling stop in Bogota, but did not make that stop as Bogota is just slightly closer than Medellin. A stop there for fuel would have raised awkward questions about inadequate fuel planning. Another possible refueling stop was available in Iquitos, Peru, but would involve a two hour notification for customs and prior permission to enter Peruvian airspace from the DGAC (Bolivia's Civil Aviation Authority).

A Roll of the Dice

We must remember that the captain of that doomed airliner did not get up that morning with any idea that his actions would end up killing himself and his passengers. His essential error was that of what safety experts call "expectation bias". Simply put, the human brain has an expectation that things will work out in the future as they have in the past. The result of succumbing to expectation bias is that it effectively masks the underlying risk of one's actions.

In the back of our minds all pilots "know" that the risk of screwing up badly is an untimely meeting with the grim reaper. Pilots are famous for making macabre jokes about death even as aviation has grown safer. But with such sentiments being always present throughout a career in aviation, it becomes ever easier to believe that bad stuff only happens to the other guy who got unlucky. The fact that any particular pilot is around to reflect on the demise of compatriots can actually reinforce the belief that he or she is doing it right.

Now contrast that omnipresent but dull sense of risk of a crash with the very clear and present fear of the consequences had these pilots not gotten the beloved Chapecoense football team to their championship match. The pilots likely thought that cancelling the flight was not an option as the match was scheduled for the next day. The captain, and the airline of which he was part owner, would have suffered tremendous enmity and a loss of future business when it was learned that they were the cause for the team to miss their game or to arrive without the needed rest to play the next day.

There is little doubt that the captain knew that fuel was going to be tight, but he conflated the risk of running out of fuel with the risk of not getting the team to the game. He rolled the dice without understanding how many chips were on the table.

The question is, how does one person get put into the position of making a decision between an uncomfortable outcome that is certain to happen (if the flight cancels) and a deadly outcome that might or might not happen (if the plane runs out of fuel)? Had the plane not run out of fuel 10 miles from the airport, no one would have been any the wiser.

Depending on the Kicker

Any organization depends on cooperation between individual team members to be successful. Success or failure should not, however, be dependent on the actions of one person. Like any complex machine, an organization must have redundancies for critical functions. Too much stress on a critical link in any chain guarantees eventual failure. If winning the game always depends on the kicker, the team has failed.

The captain of LaMia 2933 should not have been in the position to be able to trade safety for financial gain. This crash was due not only to a bad decision made by the captain, but also to the organization which allowed one actor to be pressured to make such a decision. So how should an organization insulate itself from this type of single point failure?

Culture of Safety

First, in any industrial setting, cultivating a "culture of safety" is paramount to a successful operation. What this means is that safety of the operation is first and foremost. This culture must be internalized by everyone from senior management to entry level and temporary employees.

Successfully installing such a culture is hard work and will not be accomplished through mere platitudes or safety posters hung in the workplace. There will need to be honest organizational support for safety initiatives and a reassurance from the C-Suite on down that the goals for a safe operation are embraced. This will include a robust safety reporting system and employees who are empowered to implement correctives for identified deficiencies.

Secondly, individual employees should not be put in a position of having to choose between a competing set of values. In the case of airline operations, the people in charge of financial results are probably the wrong people to be making operational decisions that impinge on safety. The bottom line must obviously be watched, but if an operation cannot be done safely, then it probably shouldn't be done at all. Management tools such as pay protection for line employees when operations are cancelled can help in the effort to make sure the correct decisions get made.

The Choice is Yours

Whether you find yourself as a manager or operator, you must understand that humans respond to incentives. Wrongly aligned incentives will eventually manifest themselves by coming back to bite the unwary. Is your organization optimized to be as safe as it can be? How will you know if it isn't?