But It Wasn’t Broken Yesterday!

My friend’s girlfriend has a funny reaction to when things break around the house. She often says, “But it wasn’t broken yesterday!”, as though as something being in working condition the day before should affect the working condition of the device the following day. By definition, things break in an unpredictable fashion. It’s interesting how things fail both in terms of devices and systemic failures in organizations. Furthermore, it is even more interesting how we react to failure, make sense of it and how we make changes for the future. By definition, accepting failure is accepting a loss, something we struggle with as humans. We will study this by looking at the systemic failure of safety in my glider club and possible ways to change the club’s safety culture.

Yesterday, one of our club members had crashed and destroyed his own sailplane about ten miles away from the airport. So far, we don’t know the full story surrounding the accident, but the fellow had recently purchased the glider and was inexperienced with cross country flying and flying in this particular area. He had survived the accident and was medevaced to a hospital and hopefully he will recover soon.

Naturally, we question why this happened and we look for the signal in the noise. Prior to this accident, we had two other accidents over the past eight months that were also by inexperienced pilots, or experienced pilots flying in unfamiliar territory. One accident resulted in minimal damage, but entirely due to blind luck. The second resulted in the total loss of the person’s own sailplane. In both cases, the pilots were unhurt, however both accidents had a very high risk of substantial injury or death. The year before, one pilot completely destroyed his glider in an off-field landing attempt. Prior to this, we had a long stretch with a good safety record.


Events happen unpredictably and there is not necessarily a reason that they happen at a particular time. However, if you look at underlying factors, perhaps you can find a pattern and realize that there are ways to change this behavior. A device may break due to simple random wear, which would generally follow a statistical distribution. However, if a device is improperly used, the device may break in an unpredictable fashion. Maybe it would run the course of its useful life and still function, or maybe it would break much abruptly and much earlier. The corollary to organizations is that a given attitude or course of actions may have no effect for a while, but in reality that there is a heightened risk of failure.


At first, we need to ask if there is an apparent cause for this accident “cluster”. I don’t think there is any particular reason for the close timing of the accidents as the culture of the club has largely remained constant.  Little notably changed over the past year to have caused these events. However, I do believe that the events are the result of a pattern of the club’s consistent approach toward safety. As a result, we need to take a close look at the organization.


Aero Club Albatross as an organization is not great from a safety perspective. While one of the best things about the club is that it encourages new pilots actively pursuing soaring and is quite lenient about the use of its equipment, we do not do a great job of keeping track of other pilots. Three of the four recent accidents were due to inexperience. 


One of them was due to the pilot feeling pressured to fly even though he did not want to, flying in an unfamiliar area. The second pilot crashed in an area known to be highly dangerous to the more experienced pilots while attempting to make a big flight. Lastly, yesterday’s accident was by a new club member. All three show a consistent pattern of lack of experience with the technical nature of the sport, or simple inexperience with the local area.


The good thing is that by recognizing that there is a pattern, we could recognize that there is a problem and find solutions. We need to be more active in the pursuit of safety, rather than passively say that each person is responsible for themselves and their own actions. Let’s see what we can do differently as an organization and make everyone is safer.


First off, we need to recognize that there is a problem.

We cannot accept that every other year or so that a pilot from Blairstown will likely destroy their glider and put themselves in serious risk. There are externalities that result from each accident that affect our reputation in the township and the soaring community. There are also far-reaching effects within the club, which diminish enthusiasm and involvement of our club members. Each accident affects all of us and we all suffer when our friends crash. It is not fun when people crash or realizing that this is a dangerous sport. Lastly, accidents are horrible publicity when it comes to trying to promote the sport and attracting new members. 


Secondly, we need to change the attitude and discussion about safety. 

Since we are all affected by such accidents, we need to play a more active role in managing safety. The ways we can do that are:


1) Speak Up: Whenever anyone sees someone or something that is going wrong, they need to say something. We first start with communication. It does not matter who the person is, or what their experience level is. Communicating has no downside! 


2) Listen: Beyond encouraging communication, everyone needs to make a commitment to openly and heartily accept advice and criticism. Most pilots are Type A personalities, which are highly motivated, somewhat macho and goal oriented. The flip-side is that as a group, we have huge egos. It is stupid to get killed because of one’s ego! No matter how the experience level, if a person goes out of their way to provide advice, again there is no loss! On a rational level, by them providing direction, the pilot on the receiving end can only benefit! The worst possible case scenario is the pilot only loses five minutes of their life to a pointless discussion. The best possible case scenario is that their life is saved later! Each pilot should create a reputation as being approachable and enthusiastically accepting feedback in order to encourage and reinforce other pilots for taking the time for providing it.


Now, I do recognize that you cannot entirely get rid of personalities and ego when it comes to these sorts of discussions. Here are a couple piece of advice to have more effective dialogue and how to bring about successful changes in behavior. We will look at the two sides of the conversation, the sender and the receiver.


For the sender-


1) If you recognize an unsafe situation, you have a responsibility to communicate. You are your brothers keeper.


2) If the unsafe situation requires immediate action, try to communicate with receiver as soon as you can safely do so. For instance, if you are assembling your glider and you witness another pilot about to take off with their tail dolly on, drop what you are doing and alert the pilot immediately of the situation.


3) If the situation is a discussion about judgment and does not require immediate action, then it is best to communicate to the receiver in an environment that is most suitable for them to effective communication.


Generally speaking, this means in a relaxed fashion and NOT in a group setting. Inevitably, bringing up any safety related questions will conflict with the receiver’s ego. The goal is minimize this as much as possible and maximize the rational components of the discussion. The best way to do this is one on one, preferably face to face at the end of a flying day. Otherwise, it is best to talk on the phone. Email is least preferable because the more removed the receiver is from the sender, the harder it will be for them to recognize their actions and change their behavior.


4) The actual conversation


– Have the receiver do most of the talking. Ask them about how that flight went and gently bring up what had went wrong. Most of the time, the receiver already recognized their own error and is rather embarrassed by the whole situation. If the person understands and recognizes the situation, then there is little reason to continue. If not, then this is the educational opportunity where the sender can point out the risks associated with the given behavior and the necessity of changing it.


– Do not cause unnecessary fear or be threatening in any fashion. The old school approach of lashing by tongue is ineffective. It may cause a person to become fearful and change their behavior in the near term, but the more lasting result is that the receiver will become fearful of interacting with that sender again and will conceal their actions in the future. This in turn breeds a culture of fear within the club and limits dialogue and discussion. In turn, the result is ultimately counter-productive to improving the safety culture. Furthermore, the sender acquires a reputation of not being approachable and is unlikely to be alerted of his own errors in judgment. No one is immune from mistakes.


– It is very important that the sender separates himself from the discussion and does not put promote his own ego. The heuristic that the receiver will follow is that, “The sender does not like me.” This needs to be set aside as early as possible by an affirmation that the discussion is friendly and that the sender is simply trying to be helpful.


For the receiver:

Unfortunately, most of the time discussions about safety, senders fail in some of the points listed above. There’s no question that it often really sucks being at the receiving end and it is very hard to accept the loss that we are possibly doing something wrong. However, no matter what, the discussion still could only have a positive impact on your flying. Listen and be rational. Suppress your ego. Even if the discussion is unnecessary and futile, let the person say their piece and be receptive and kind to the criticism. Create a reputation that you accept feedback readily and respectfully and it will pay dividends in the future.


As an organization, we should assign mentors to new pilots

Other than pilots taking the initiative when they see something wrong, each pilot should have an experienced mentor assigned to them. By opening the communication channel from the very beginning, this would facilitate and encourage discussions about safety and technique and improve the overall safety of the club. Furthermore, by providing a mentor, this should increase our retention rate of members as they will have someone keeping tabs on them and facilitating their progression through the sport.


Closing thoughts


In summary, we need to accept that we have a problem and do something about our club’s safety culture. The recent accidents are not the result of bad luck, nor are they specifically correlated to each other. Instead, it is the systemic failure of maintaining healthy dialogue and attitude about safety. As a result, we need to be proactive and make several important changes to our culture to avoid such unfortunate events happening in the future. Failure to do so would have many negative effects within our club, sport and community.