Friday, 8 May 2009

Rules & Procedures are not enough

Blue Eyes recently wrote a post calling for responsibility on the part of professionals in the public service, reminding them of the tort of negligence. Like me, he does not like to see the retreat behind the mantra of "procedures were followed" that so often precedes a shirking of responsibility. Stuart Sharpe picked it up, and we had a good debate there around the pros and cons of the law of negligence. I now want to add this story, to illustrate that it is not enough to put procedures in place. You have to exercise the faculty of critical thought as well.

Of all tasks, the one that probably has the most rigid procedures is flying. I learnt to fly when I was younger, all at Her Majesty's expense (thank you, Ma'am). An essential skill for any putative pilot is that of rote learning, as there will be innumerable procedures that must be learnt and followed to the letter. They cover all possibilities, such as how to check the aircaft prior to each flight, a pre-take-off checklist, a during-take-off checklist, and after-take-off checklist, and so on. There is even a list of stuff to do when there is nothing else to do (basically, look out of all the windows and peek at the major warning lights).

Of greatest importance are the emergency checklists, from "fire in the cockpit" to mere "radio failure". I did have to use the latter once after an electrical fault; fortunately I never needed the former. Actually, the "fire in the cockpit" drill is rarely used; as my instructor explained, he wasn't paid enough to stay in a burning cockpit and would therefore move straight on to the "abandon the aircraft" checklist. Anyway, these emergency checklists are learnt by rote by all - even civil private pilots, who are often derided by RAF jocks for walking round their aircraft, printed checklist in hand, unable to recall the list perfectly from memory.

This story is one that I read in an accident investigation report. These are circulated around all pilots so that they can learn the easy way, after someone else has learnt the hard way. This story concerns an inexperienced civil private pilot, who was flying cross-country with a friend in a borrowed aircraft. She noticed a distinct smell of burning in the cockpit, and immediately reported this to ATC, informing them that she intended to carry out a forced landing in view of the danger. Now, if you are a civil pilot with (probably) no parachute, and you are in control of an aircraft that is on fire, this is a very good idea. Also a good idea is to shut the engine down quickly and isolate the fuel system. Most fires in aircraft come from the engine, probably due to the very high temperatures that are present, and the large amounts of highly flammable liquid that is pumped into them. Electrical fires also happen, and are more rare but more likely to be in the cockpit.

To distinguish between these possibilities, there is a cunning trick that a pilot can use to see where the fire is. I remember being taught it by an RAF instructor; it involves looking for bright red hot flamey things. If you can see those, they often indicate the location of the fire with eery accuracy. If they are coming out of the engine bay in front of you and licking past the windows on the outside, then the fire is in the engine. If they are visible though the dashboard, inside the aircraft, then the fire is in the cockpit and probably not to do with the engine. If you can't see any hot red flamey things then the problem is probably something different.

We don't know if she did this check. All we know is, she shut down the engine and carried out a deadstick forced landing in a field - entirely correct procedure for an engine fire, although quite challenging in practice. With no engine, the approach to the landing is steeper, and you only get one chance to get it right. Even a practice forced landing is quite stressful, and when you get it right there is quite a feeling of achievement. In a real forced landing, I understand, that feeling of elation is usually ruined by an angry farmer pointing at the damage to his crops. Especially if your aircraft blows up just after you run away from it.

The accident investigation, however, revealed that the cause of the smell was a blown fuse. In the process of blowing, it had overheated a bit and singed the plastic cover of the fuse box. Hence the smell. Had she realised this, she could easily have carried on to her destination with no danger - the circuit concerned was a minor one. Instead, she followed her procedures blindly and to the letter. Examination of the aircraft showed that she had correctly shut down the engine as required in the "engine fire" checklist, and and shut off the fuel supply correctly. Sadly, she was following the wrong checklist entirely, purely because, probably in a state of mild panic, she did not stop and think.

So; why was there a full accident investigation report for me to read? Because she cocked up the forced landing, hit an obstacle, and died.


  1. Pretty much sums it up. Learning by rote is just not sufficient. One must be able to engage brain as well.