Sunday, August 9, 2015

#Phenom300 #HZ-IBN accident on 31 July: The Erring Human Strikes Again!

An #Embraer #EMB-505 #Phenom300 jet was destroyed when it crashed into a car auction next to Blackbushe Airport, U.K., killing all four occupants. UK AAIB has opened an investigation into the accident and a special bulletin was published on 06 Aug 2015 that can be downloaded from this link.

HZ-IBN just seconds before crash (Photo by Geoff Pierce)
In summary, #HZ-IBN, entered the left-hand circuit for runway 25 at #Blackbushe via the crosswind leg. Towards the end of the downwind leg, it overtook a micro light aircraft, before climbing slightly to pass ahead of and above that aircraft. Several TCAS Resolution Advisories were issued to the pilot during the manoeuvre.
Following this climb, HZ-IBN then descended at up to 3,000 feet per minute towards the threshold of runway 25. When HZ-IBN was 1.1 nm from the runway threshold it flew at 1,200 feet above airfield level at a speed of 146 KIAS, with the landing gear down and flap 3 selected. The target threshold speed for the aircraft was calculated to have been 108 KIAS.
The aircraft continued its approach at approximately 150 KIAS. Between 1,200 and 500 feet the rate of descent averaged approximately 3,000 fpm. The aircraft’s TAWS generated six ‘pull up’ warnings on final approach. The aircraft crossed the threshold of runway 25 at approximately 50 feet at 150 KIAS.
Tyre marks made by the aircraft at touchdown indicated that it landed approximately 710 m beyond the runway 25 threshold. Runway 25 has a declared Landing Distance Available (LDA) of 1,059 m; therefore the aircraft touched down approximately 349 m before the end of the declared LDA, 438 m before the end of the paved runway surface. The airspeed on touchdown was still 134 KIAS. At this speed the landing ground roll required to stop the aircraft would be at least 616 m.

The aircraft departed the paved surface at the end of runway 25 approximately three metres to the left of the extended runway centreline. It then collided with a one-metre high earth bank causing the lower section of the nose landing gear and the nose gear doors to detach. The aircraft became airborne again briefly, before colliding with several cars parked at an adjacent business and coming to rest approximately 70 metres beyond the earth bank. The aircraft’s wing detached from the fuselage during the impact sequence and an intense fire developed shortly thereafter, consuming the majority of the aircraft. All the four occupants including the Captain, flying solo, were killed in this accident.

It is clear from the above discourse that the approach was un-stabilized and should never have been continued. Yet, it was. The Captain was 57 years old with over 11,000 hrs. of total experience (of which 1,180 hrs. on type), and was personally known to me. He had participated in many training sessions on SMS and CRM conducted by me. I had also been involved in development of both, the operations and the SMS manuals, for the operator as a part of their IS-BAO certification in 2011. In this sense, I feel deeply affected by this tragedy. He was not a reckless man. Yet, he seemingly continued an un-stabilized approach and the comment from his employer, “…Such an experienced Pilot! How could he!” shocks me more than anything else about this tragedy.
The comment is a reflection of total lack of understanding of Human Factors in aviation operations. This in itself gives us a clue on why this accident happened and how a well-qualified, properly trained and experienced human was forced to err! This accident is also an almost exact replica of the #IX812 crash I had written about in my book “Waiting…To Happen!” and has occurred for almost the same reasons! Un-stabilized approach, very high rate of descent, very high landing speed, touchdown 2/3rd way up the runway with not enough runway left to stop the aircraft…the sequence is eerily similar!

Human error is a symptom, not a disease. It is a start point of an investigation, not its conclusion. All human performance happens inside an organizations policies and procedures. It is those policies and procedures that set in motion a “latent conditions” trajectory, setting in motion a chain of events that culminates into a human making an error and ultimately an accident. The aircraft was not being operated in an individual capacity, but under the AOC of a company and following the policies and procedures as set by the management team. An accident of this nature is a clear evidence of the management team’s failure to manage the aircraft and to ensure safe operation of its aviation assets. It is clear that the Operations and SMS manual contents were not being applied on ground in their letter and spirit. It is not enough to have a good manual. It is important to be able to understand that manual and then apply it, consistently and judiciously, in the company’s daily operations. It is painfully evident that the company failed it its objective of consistent and judicious management of safety. The accountability for Safety Management rests with the Accountable Manager, in this case the Managing Director, and that is where the questions need to be raised. This is a failure of the Managing Director to manage safety, and he has a lot to answer for!
Management of safety does not happen by making statements like “Safety First” and “Safety is Everyone’s Business”. Safety is NOT everyone’s business. It is the business of the Accountable Manager, and Accountable Manager alone. By making a statement like “Safety is Everyone’s Business” the Accountable Manager seeks to escape his responsibility and creates a situation where somebody should do something, everybody could do something, but nobody does anything! Instead, the Accountable manager would do well to lead by example and take the bull by its horns by owning-up his responsibility, accountability and his failure. Things need to be set right by acknowledging that “safety first” is wrong notion to perpetuate. No organization, not even ICAO, was formed totally and only for safety. Every organization has a primary objective of service delivery. This service must be delivered safely, but it must first be delivered! This is what needs to be understood. By making statements like safety first, the management sets in place a paradox. It creates a false feeling of security where adhoc decisions are taken in the name of safety. It is important to always remember that Safety is not accident prevention, but risk management. It is true that management of risks will prevent accidents, but that will be a corollary to the theorem. Primary focus needs to remain on management of risks rather than on prevention of accidents. The end product of the company, in this case the service, must be delivered safely; otherwise, it is not delivered at all. So, safety needs to become a way of life…the way we do things around here…identifying hazards and managing risks before any activity, implementing risk controls, allocating responsibilities, monitoring implementation of risk controls, collecting and evaluating feedback and repeating the process again, and again, and again…endlessly.

For this process to work, it is important that Safety Management is managed at the same level as other business processes like Financial Management, HR Management, Marketing Management etc. The most common failure is seen in placing HR, Financial, marketing etc. in primacy over Safety Management, thereby setting in place conditions ripe for failure of the Safety process. This often happens because safety is seen as a non-productive process, an expense item on the balance sheet. Also, lack of understanding of Human Resources Management by even some HR professionals results in creation of this paradox. Humans are treated like objects. They are sought to be managed like objects. Policies and procedures are not applied across the board or consistently. These conditions create an environment where the humans see a difference in the written text and the implementable rules. They are quick to catch the difference and follow what they “perceive” to be the Managers intent! While their perception may or may not be correct, they will always do what they perceive is required by their manager rather than what was meant by the words spoken to them or text written for them. Moreover, the management keeps wondering, why the humans cannot follow simple instructions, little realizing that they are actually following the instructions they perceive rather than what they read or hear!
This is the real challenge in development of human resources. Human resources cannot be managed. They can only be developed. They can be developed by providing a leadership that leads by example. A manager who routinely flies his aircraft certified to 16,000 ft altitude at 18,000 ft to take advantage of favourable winds, because he believes that the certification standards were not applied correctly or one who deliberately mishandles aircraft engines in flight “to seek the limits of the aircraft” does not set a good example for his employees to follow. If he applies adhoc methods to manage humans, by displaying lack of respect, by harassing someone when the person is down and vulnerable, by applying salary deductions and even withholding salary of an employee based on his perception that that employee is dishonest, again sets an example that conveys a message of “anything works here as long as you don’t have an accident”! Such a manger can never manage safety and will always end with accidents of the nature of #HZ-IBN.
Management of safety in Aviation operations is not for the faint hearted. It needs a huge amount of data to be processed, policies to be administered and processes to be managed. The only way to achieve this objective is to manage humans humanely, to be consistent in application of all policies and procedures. The message that needs to go across is that having an accident/incident is not a crime, but deviation from a Policy or a Procedure is a crime, always and every time.

#HZ-IBN crashed because of a Management failure. The failure to manage safety. The failure to implement the safety risk management process. The failure to understand human factors in aviation operations. The failure to create workplace conditions conducive to high-risk environment. The failure to assess workplace hazards and mitigate the resultant risks. The failure to reinforce defences. The failure to monitor and deal with errors and violations. In short, a failure of the Accountable Manager to remain accountable for the operation!
This provided an opportunity for The Erring Human to strike again, with a tragic loss of four lives. There is a lot for the owners and managers of the company to contemplate over. In the tragedy lies an opportunity for change. In this tragedy, there is an opportunity to rid itself of its sorry legacy and make a course correction, so that yet another tragedy can be averted. An attitude of self-righteousness and outrage will not solve any problem. First step in correcting a problem is in acknowledging that a problem exists and needs to be fixed. Once that step is taken, the rest will follow naturally and optimistically, a resilient organization would result.
Stay Safe,
The Erring Human.