Doing It Right: How Mistakes Illuminate A Safer Path


This month’s doing-it-right mention goes to my friends at Skydive City, my home drop zone in Zephyrhills, Florida. Last week, in a sporting crosswind, the DZ’s Twin Otter had a runway excursion of the sort that happens every day in general aviation. The Otter is built like a locomotive so damage to the airplane was limited to a scuffed-up control hinge.

What happened post-incident is a case study in how such events can yield a positive push to prevent the next one from happening. I think in many such incidents, the cause is filed under s%$t happens or the pilot is assumed to have failed to deliver on his training or skills. Maybe. But that disposition stands little chance of conveying a useful educational moment. Over the weekend, DZO T.K. Hayes told me the company conducted its own in-house post mortem in the spirit of the kind of inquiry that yields things you don’t always expect.

He showed me a list with a dozen action items that enumerated why the incident might have happened and what procedures might be followed in the future to avoid a re-do. All of the items were thoughtful and penetrating, including reconsidering what training the pilot had and what remedial work he might need.

But one item stood out for me. It has to do with what I call “the culture thing.” Be it airlines, charter, crop dusting or banner flying, a certain go-go attitude can infect a flight operation where profits are a goal. For a jump pilot flying 20-minute turns at a busy drop zone, landing and taking off on the closest runway to the aircraft loading area, irrespective of wind, is a given. It cuts minutes off the turn time. And time being money, you know the rest.

But the PIC is the PIC and Hayes was sure the pilots hadn’t been pressured to push the airplanes to the crosswind limits or their own comfort level just to save a couple of minutes. And I’m just as sure pilots will pressure themselves to do this because I’ve flown in commercial operations and I surely did it. And I’m an average kind of guy about stuff like this.

So Skydive City’s inward-looking response was to reiterate that PICs make the decisions on such things and can expect the unconditional support of management to do so, especially with regard to pushback on weather conditions. It’s really just re-enforcing what every pilot knows, but like muscles that atrophy if not exercised regularly, it’s easy to forget that you can and should just say no once in a while. Having a corporate culture that spares consequence from such decisions stiffens the spine and just makes, if not a safer atmosphere, one in which a profoundly egregious oversight is less likely to occur. The macho, I-can-do-this attitude is ever present. In the imaginary world all of us wish we inhabited, accident/incident investigation is a reductive process that doesn’t seek to assign blame, but to impartially devise solutions. But blaming something or someone so neatly ties the knot that it’s hard to avoid it.

In it’s internal probe, the DZ also plugged a minor gap in its communication procedure that could have made a difference. As they sometimes are, the AWOS at the airport had been broken, but the drop zone has its own wind system, with an indicator that’s not convenient to manifest. Now, there will be a wind data repeater where the radios are, providing the pilot with an option that puts another stitch in the safety net.

Wouldn’t it be heartening if every accident or incident were followed up in this way independent of government or insurance investigations? A consciousness of safety comes not from government edict, but self-informed survival instinct. That usually doesn’t happen of its own, but accrues from the will to self-examine and learn from mistakes, no matter how minor.