Our choices determine risk
Sometimes it's the little thingsThis is the final installment of a series on risk management. The series explores the common need for, and techniques of, managing risks in two arenas: aviation and mountain climbing. The premise is that both activities, although very different in terms of skills and knowledge required, share similar problems with decision making and hazardous attitudes that have often lead to preventable accidents. Since the problems are common, it is likely that the techniques used in each culture to minimize or eliminate the inherent risks should apply to the other. Author Ken Wittekiend came up with the idea for the series after reading No Shortcuts to the Top by renowned climber Ed Viesturs.
Marty Hoey, one of America's leading women climbers, was on an expedition to Mt. Everest in 1987. She was climbing in a routine situation, seemingly safe, connected to a fixed rope by her waist harness. As she leaned back to let a teammate pass, her harness released and she fell to her death while her teammates watched in stunned horror. Ed Viesturs writes in his excellent book, No Shortcuts to the Top, "It was later surmised that Hoey had made the simple mistake of not back-buckling her harness. Without that double insurance, the webbing of the waist loop can actually slide through the buckle under tension."
Often, we get away with small lapses in judgment. Little mistakes are quickly corrected and nothing bad happens. But sometimes-when fate, bad luck, karma, or random chance intervenes-tragedy happens. Pilots often hear about the wrecks that occur when things go really wrong. However, many of us have a pocketful of stories where, thankfully, it just wasn't our day to die. I remember taking off in an old T-34 Mentor from a grass strip when suddenly the seat disengaged and slid to the bottom of its travel. I found myself looking up at the instrument panel with almost no view forward. It would have been very easy to pull back on the control stick in an attempt to raise myself up enough to see where I was going and end up in a stall or spin. I was able to get the seat back up into place and continue the flight. Afterwards, I became much more serious about checking the seat latches.
Viesturs also tells about a Taiwanese climber who, needing to relieve himself, decided to step out of his tent without clipping into the fixed ropes or taking time to put on his boots. Wearing only the slick inner boots, he slipped and fell down the face some 70 feet, sustaining fatal injuries. In one small mistake, tragedy struck. His fellow climbing partners were too distraught to continue and left the mountain for home, carrying the body of their friend.
So what is at work here? Is it complacency that leads us to make what seem to be inconsequential mistakes? Complacency is really a failure to recognize the inherent risks and to act appropriately. When combined with the right mix of circumstances, it is enough to lead to disaster.
Bolstered by a history of successes in similar situations, we simply come to believe we can always get away with it. Darren Smith describes a student who refused to use the electric boost pump in his low-wing trainer, believing it unnecessary. After all, the engine-driven pump had always worked until one day, when it did not. Luckily, the airplane ended up on a nearby highway with only minor damage.
Many of us know instrument pilots who think nothing of taking off in low IFR conditions in single-engine airplanes or who routinely bust minimums, trusting that they can get away with it. John Eckalbar, writing in Instrument Flying Update, describes a 2004 event where a professional crew flying a Beech 99 on an ILS approach initiated a missed approach after two low-altitude alerts were issued by the tower. The weather was awful with a ceiling 100 feet indefinite and one-quarter-mile visibility. The aircraft diverted to a nearby airport and the landing gear collapsed on touchdown. In the accident report, it was determined that the damage to the gear occurred during the earlier approach when an examination of the roof of a building located about 1.65 miles from the runway revealed two impact marks matching the gear on a Beech 99. The decision altitude on the approach was 3,784 feet and the building roof was estimated to be about 3,750 feet. Talk about lucky! Talk about dumb! The well-known hazardous attitudes certainly apply here. Anti-authority, machismo, invulnerability-all were present in some amount.
So what lessons can we take from these examples? Perhaps we begin with situational awareness. Pilots are often schooled to keep up with where they are and what will be coming next. By focusing on his or her present situation, the attendant risks will be more evident. Knowing that a small misstep on an icy slope can lead to a fall makes us stop and put on our boots. Being aware of the appropriate minimums for each segment of an instrument approach keeps us out of the weeds.
Discipline is also a factor. By following checklists and procedures we should be able to minimize errors. This means always following the routines and avoiding shortcuts that can lead to that first step down the slippery slope to disaster.
Maturity enters into this as well. Pilots who avoid showing off and pushing the limits will enjoy a far safer flight. There is a balance between boldness and brainless that is often ill defined. The pilot usually knows when the risks are piling up but sometimes decides to press on anyway. Then, because we usually get away with it, a lesson is learned. In the best case, the lesson is, "I never want to do that again." Sometimes, it is, "That wasn't so bad. I guess I'm good enough that the rules don't really matter."
It is no huge revelation that small mistakes can roll up into big disasters. Pilots have read articles extolling the virtues of risk management for years. Remember that each of us makes choices. Those choices often determine the amount of risk we will have to deal with.
When things go wrong, we need to recognize that although we may have acted alone, others share the consequences. The potential costs of our mistakes in terms of the damage we inflict on our spouses, children, and friends are high-it often can continue beyond our own lives. Knowing all of this, hopefully, we will stop and think carefully before doing something dumb.
Ken Wittekiend, a Gold Seal CFI, CFII, and FAA FAAST representative, owns Promark Aviation Services in Burnet, Texas. He owns a Beech Bonanza and a Piper Super Cub.
By Ken Wittekiend