From Joe…Staton West is an Instructor Pilot, Instrument Flight Examiner, and Pilot-in-Command in the US Army in both fixed and rotary-wing aircraft, has been deployed to war zones more times than you have fingers, is a true aviation aficionado, and one of my best friends. I make every effort to publish just about anything he writes as there is always a harvest of golden nuggets available…I bet you agree…
Have you ever made a mistake? Of course not, but I have – many of them. I’ve even made mistakes while flying helicopters and airplanes in the Army and while piloting my own personal aircraft. I’ve made mistakes as 250 hour pilot and as a 2,500 hour pilot. Fortunately my errors amounted to nothing more than a bruised ego and a subsequent barrage of thankful prayers. I am more adept at forgiving myself for errors due to ignorance than the ones due to stupidity – the “never-again” moments from which I miraculously walked away seemingly unscathed. The good news is that I learned my lesson on many accounts and pledge to never again have a never-again moment.
As a First Lieutenant, I led a Forward Support MEDEVAC Team during an operation in Saudi Arabia. It was an exciting time for me as a junior Army leader and as a newly designated UH-60 Blackhawk Pilot-in-Command. The three-month deployment was less than challenging, for though we were poised to respond around the clock to medical emergencies on and in the vicinity of the airbase, the call never came. This is a good thing, obviously, for our military beneficiaries – but not so much a good thing for a group of bored Army aviators. This boredom manifested itself during our training flights and the “incentive” flights we conducted for our Air Force counterparts at Prince Sultan Air Base. I can easily blame the group of whoop’n and holler’n jet jocks strapped in the back of my Blackhawk helicopter for spurring me down to 15’ (yes, that’s fifteen feet!…) above ground level at 135 knots indicated airspeed – but I won’t. It was all me and a desire to appear equally skilled and cool as my passengers. The never-again moment – the one that truly changed my life – happened on a subsequent flight. Apparently 135 knots while only fifteen feet off the deck (doors open!) wasn’t cool enough. I just had to push it further to make sure my passengers got the ride of their lives. A moment of both ignorance and stupidity, I had no business doing the maneuver that led to loss of tail-rotor effectiveness – a condition almost unheard of in the Blackhawk. In about 0.72 seconds (an eternity) the tail of the helicopter spun out of control by approximately 270 degrees. The F-16 pilots strapped in back cheered, Igor Sikorsky shrugged, I prayed and cursed at the same time, while God smiled upon us all that day and sent the ship home at a nice and easy 100 knots indicated airspeed some 500’ above the ground. Never again…
Other mistakes have been less deliberate but equally stupid (read human) like the time I attempted to depart in my AA1 Yankee with the tow bar still attached to the nose wheel. Bless the nearby transient pilot who called my attention to it. Again, a bruised ego was the result – particularly since my not-so-much-into-flying-in-small-airplanes wife was with me. (Glad it wasn’t our first date!) And then there are the honest mistakes that rest in the realm of my being that I like to call “experience.” These are the ones from which I have learned a tremendous lot about…well, almost everything, particularly about flying and aviation in general. None of us like to err, but the fact is we inevitably will, so it is incumbent upon us all as professionals to learn from our mistakes and the mistakes of others. This can only happen if we agree to openly air our errors with the hope that others can benefit from the lessons that come from making mistakes.
In my opinion NASA’s Aviation Safety Reporting System (ASRS) is perhaps one of the most innovative and necessary aviation safety programs in history.
This cooperative safety reporting program invites pilots, controllers, Flight Attendants (F/A), maintenance personnel, dispatchers, and other users of the National Airspace System (NAS), or any other person, to report to NASA actual or potential discrepancies and deficiencies involving the safety of aviation operations…The effectiveness of this program in improving safety depends on the free, unrestricted flow of information from the users of the NAS. Based on information obtained from this program, the FAA will take corrective action as necessary to remedy defects or deficiencies in the NAS. (http://asrs.arc.nasa.gov/overview)
The key words in the preceding paragraph are “free, unrestricted flow of information.” This is possible due to the non-punitive nature of the program thereby giving would-be respondents freedom to openly report errors or discrepancies without fear of reprisal – unless of course errors are the result of gross or criminal negligence or in blatant violation of Title 14 of the Code of Federal Regulations (14 CFR). Certainly there are obvious circumstances when it is appropriate to assert blame due to willful misconduct; however, such instances are fortunately few and far between in aviation. Efforts to uncover the anatomy of human error in aviation benefit more from a systemic approach rather than a “name, blame, and shame” approach. In other words, inevitably there exists a chain of events – latent conditions that enable these events to occur at precisely the right moments within a given system – that ultimately leads to an accident. Error reporting programs such as NASA’s ASRS are used to seek and correct system deficiencies in an effort to break error chains. The organization publishes a monthly newsletter entitled “CALLBACK” that highlights lessons learned from various incidents and a wide variety of topics. One can view and download current and back issues at the following address: http://asrs.arc.nasa.gov/publications/callback.html
No matter the scope or scale of one’s participation in aviation, we as participants are all part of a system. And because we are human participants in this complex system, errors – even chains of errors – exist. Learning from the experiences of others, good and not-so-good experiences, is a safe and efficient way to learn. Sitting around a group of pilots telling so- there-I-was-inverted-pulling-so-many-Gs-I-was-in-the-Hs stories is valuable time spent. No matter if the stories are true, half true, or far from the truth, there is usually a lesson to be learned. This is why it is so important to have a mentor or network of individuals with whom we can share our stories and experiences. That “never again” moment you share with others will most likely be met with a “been there, done that” response or two. Perhaps not, but know that you just imparted a bit knowledge based on experience that one day may enable others to break the error chain.
Staton West, CW2, US Army