Inherently Dangerous: Inside and Outside the Box

Flying Safety, May, 2001 by J.S.T. Ragman

Not one of those pages would have helped in any of those mishaps.

The semi-annual sim-check was two weeks away. Making good use of the ten-hour flight leg. Review the limitations. Review the abnormal procedures. Review the emergency procedures. Review the checklists. I had been doing so for years. And then came the Concorde. And Alaska Airlines. And Swissair. And ValuJet. And TWA.

As I flipped through the checklists and procedures, and gazed upon the Northern Lights over Greenland, my mind wandered. A blown tire, ruptured wing fuel tanks, two engine failures on takeoff, unable to retract the landing gear. A stripped nut, loss of the horizontal stablizer, no hydraulic control, no electric control, no manual control. An electrical fire in or near the cockpit, toxic smoke and fumes, no electrical isolation procedure. Improperly labeled cannisters, improperly stored cannisters, a super-hot cargo fire, and no time. An empty fuel tank, possible vapors, a stray electron, a short, an arc, an explosion.

One hundred and sixty-six pages of "abnormal" and "Emergency" procedures. Not one of the procedures would have helped in any of the above scenarios. Dozens of pages on landing weight limitations, suitable diversion airports, and phone-patch or satcom procedures for inflight technical assistance. Not one of those pages would have helped in any of those mishaps.

My mind took a path on its own, thinking over the scenarios, the checklists, the procedures. Something just was not sitting quite right in my mind. I was uncomfortable. Something was bothering me. What lessons could I glean? My thoughts came to rest upon the words of that Army Air Corps aviation poster published in the early 1900s. To paraphrase the words: "Aviation is an inherently dangerous business."

Over the course of twenty-plus years of military and airline flying, I suspect I have had a ballpark sixty sim-checks or aircraft check-rides. For every abnormal or emergency situation, there has always been an applicable checklist or procedure. Fly the airplane, find the checklist or procedure, run the checklist or procedure, dump fuel, select a suitable diversion airport, call "home" for technical assistance, land, and walk away with a smile. We are professionals. Done deal. No problem. Case closed. Top Guns. Next.

Technology, standard operating procedures, checklist discipline, human factors design, the air traffic control infrastructure, and the many other elements of the flight safety system, have greatly lessened the "dangerous" nature of aviation. With millions upon millions of departures and arrivals, crews run checklists, adhere to standard procedures, cover all the bases, land and walk away with a smile.

We are creatures of habit. We are creatures of faith. Time and again, we find the right map, we follow the map, and we find the pot of gold. Time and again, the map, the checklists, the procedures, save lives. And that is inherently, indisputably, a good thing.

Until the Concorde, the Alaska Airlines, Swissair, ValuJet, TWA. Have we allowed ourselves to become lulled? Have our habits and our faith become stumbling blocks instead of stepping stones?

Find the checklist, find the procedure. Can't find one? Look again. Still can't find one? Look for a checklist or procedure that sounds or looks right. Run the checklist or procedure. It didn't solve the problem? Run the checklist (or procedure) a second time. Run it a third time. It still didn't solve the problem? Call "home" and ask the experts. Let them find the correct checklist or procedure. Listen to the elevator music while they conduct their own checklist/procedure search.

Have we been lulled into "the box"? Have we forgotten the "step out of the box" option? Are we trained to "think outside of the box"? Or is it that an inadvertent lesson of the dozens upon dozens of scripted sim-checks is to "stay in the box"? Put another way, have we been taught that "the box will set you free"? Find the checklist, find the procedure, cover all the bases: one, two, three and four.

Undergraduate Pilot Training. Day One. "Maintain Aircraft Control. Analyze The Situation. Take Proper Action." Have we allowed our analysis step to be a mere question of "Which checklist or procedure should we run now?" Have we allowed our proper action step to be a mere matter of "Run the checklist, execute the procedure"?

When was the last time anyone announced in the middle of a sim-check or inflight checkride: "Put it on the ground now, any ground, at any gross weight. Just put it on the ground now!"? If anyone has heard such an exclamation, what was the instructor/evaluator response? When was the last time anyone has been tossed a scenario for which there was no applicable checklist or procedure; deliberately so? When was the last time any of us was trained to "step out of the box"?

The men and women who develop our checklists and procedures have done us all a tremendous service. Their efforts, and our consistently strict adherence to checklists and procedures, have no doubt saved many lives, to include our own. But has their success in anticipating scenarios and developing remedies lulled us into a mindset in which we have forgotten that "aviation is an inherently dangerous business"? Have we allowed ourselves to become mired in "the box"?