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?

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