Flirting with Disaster: How NOT to respond to safety concerns from those on the front line

BLUF: Colombia’s military successfully executed a highly publicized rescue mission in July 2008 for three American contractors, held hostage in the Colombian jungle by rebels since February 13, 2003, when their Cessna Caravan’s single engine failed during a deep jungle reconnaissance mission and they crashed. Twelve others, including the French-Colombian politician Ingrid Betancourt, kidnapped six years earlier while running for president of Colombia, were rescued with them. Less well known is that the Cessna was the first of two to crash into the jungle early in 2003. The pilots flying the missions under contract to the State Department told their management in 2002 that the single-engine plane they were flying was unsafe for high-tempo missions over the Andes Mountains. For their pains they were demoted, reprimanded, threatened with lawsuits, and, in their words, “pushed out” of the program shortly before their predictions came tragically true.

 

These notes are based on the Atlantic Monthlyarticle, "Flight Risk," by Mark Bowden, author of Black Hawk Down, Killing Pablo, and Guests of the Ayatollah.

 

http://www.theatlantic.com/doc/200907/plane-columbia 

 

(the link to this article was sent to me by Clint Lawler)

 

Key points:

 

- All of the pilots knew that the Cessna Caravans, aircraft designed to carry about 10 passengers and modified for surveillance work, were ill-suited for the task at hand...[and because there were] precious few spots for emergency landings in the Andes, the pilots felt vulnerable flying with only one engine...

- [The missions were flown] despite repeated warnings by veteran pilots that the mission risk was untenable ...veterans with long records of service, the pilots felt capable of safely flying the aircraft beyond what others considered its limits. “It’s called pushing your luck” ... “We were stupid but lucky, and we knew it, but experience counts for a lot in these situations. We were comfortable doing it, at first.”

- “[these] contracts are competitive, and the company wanted [to project the image that] we were up for anything.”

- More and more often, the small unit was asked to fly higher and higher, and deeper and deeper into dangerous country. In the summer of 2002, after flying for more than a year, the unit’s lead pilot spoke up at a company all-hands meeting in Bogotá and expressed concern about “mission creep,” warning that the single-engine Cessnas were not safe for the missions. He and the other pilots were willing to keep flying, but wanted a commitment from the company that they would transition to twin-engine planes, which the aircraft supplier was willing to offer at no extra cost. “How far do you go out by yourself at night... We had been pulling it off, but they kept asking for more and more and more. So we said, ‘Fine, but we need to upgrade the platform.’ At some point, you need to hedge your bets.” [Soule comment – not exactly an optimal safety approach. How much risk is acceptable in such situations, especially when the managers will not bear the consequences?]

- The lead pilot was relieved of his position ... and ... received [a] warning letter ... threatening termination [and] upbraided for having “a negative attitude and divisive tendencies.” [Soule – this is a clear signal of management’s support for the “front line” when someone is reassigned and upbraided for raising safety concerns.]

- [In] a six-page rebuttal letter, [the pilots] warned specifically of the danger of engine failure with the Cessnas, and included the following lines in bold and italicized type:

o “We are now telling you that this mission creep coupled with [management’s] attitude towards safe flight operations has made this mission very dangerous and creates unnecessary risk to the flight crews ... This is uniquely an issue of safety and a recommendation that will possibly save lives, limit the companies’ exposure and enhance the mission’s performance.”

o The pilots got no response to the letter [or a subsequent letter sent directly to the CEO of Northrop Grumman]. Soule comment – this has to make you wonder why they kept flying.

- The actions of management violated every principle articulated by the Weick and Suttcliff for High Reliability Organizations in their book "Managing the Unexpected."

o Reluctance to simplify,

o preoccupation with failure,

o sensitivity to operations,

o commitment to resilience, and

o deference to expertise.

 

Summary

 

In “The Logic of Failure,” the author Dietrich Dorner writes

 

“Failure does not strike like a bolt from the blue; it develops gradually according to its own logic. Complicated situations seem to elicit habits of thought that set failure in motion from the beginning. From that point, the continuing complexity of the task and the growing apprehension of failure encourage methods of decision making that make failure even more likely and then inevitable. - We can learn, however. People court failure in predictable ways. The sources of human failings are often quite simple and can be eliminated without adopting a revolutionary new mode of thought. Having identified and understood these tendencies in ourselves, we will be much better problem solvers. We will be more able to start wisely, to make corrections in midcourse, and, most important, and to learn from failures we did not avert. We need only apply the ample power of our minds to understanding and then breaking down the logic of failure.”

 

The first part of the quote is profound, the last two sentences are somewhat simplistic (since understanding and breaking down the “logic of failure” takes a lot of courage and effort to follow it through wherever it leads).