AINsight: Formula for Avoiding Disaster

AINsight: Formula for Avoiding Disaster

It is summer and I am going sailing. Each summer, I set a goal to spend more time in the cockpit of a sailboat and less time on the flight deck of an airplane. Ironically, during the summer months I read about flying and in the winter read about sailing. There is as much to learn at eight knots as there is at Mach 0.80. Many of these lessons are applicable whether you are on the water or in the air.

Seamanship and airmanship are similar—both involve the art or mastery of operating a vessel and a highly specialized skillset. Each requires not only good handling skills, but a thorough understanding of weather, navigation, communication, mechanics, rules, and regulations. Without this foundational knowledge, the captain of a yacht or aircraft can find themselves in peril.

For mariners, the classic “go-to” book to safely operate a sailboat is John Rousmaniere’s The Annapolis Book of Seamanship. Rousmaniere in addition to being an accomplished sailor is a leading authority on seamanship and safety. First published in 1983 (now on its fourth edition), The Annapolis Book of Seamanship outlines the “Formula for Disaster,” the eight contributing factors found in most marine accidents. A single factor, on its own, may be chalked up to an opportunity to learn, but the accumulation of several factors may ultimately lead to a disaster.

For the aviator, the concept of a chain of errors leading up to an accident is commonplace. Many of the factors listed below can be related directly to aviation crashes. In fact, each is linked to a high-profile helicopter crash. Here are the eight contributing factors listed in Rousmaniere’s Formula for Disaster:

1. A Rushed or Ill-considered Departure

Time pressures, whether real or perceived, are powerful and can cloud judgment. Often, delaying a departure is the safest bet. The NTSB cited “self-induced pressure by the pilot to complete the flight” as a likely contributing cause of the Kobe Bryant helicopter crash that killed nine. Waiting for the fog to lift and delaying the start of a youth basketball game is a much better outcome than flying into deteriorating weather.

2. The Route Is Inherently Risky

Choosing the wrong route may be risky. On a boat, too close to the shore may include hazards such as narrow channels, unpredictable currents, or shallow water, while too far out may expose your crew to higher winds and larger waves.

In an aircraft, the wrong route can prove to be deadly. Flying too low in areas of rising terrain in foggy conditions has contributed to many aviation crashes, including the Kobe Bryant crash. Likewise, flying in other areas, such as in mountainous terrain, requires special skills and training. As an example, strong winds can cause extreme turbulence on the leeward side of a mountain range.

3. The Route Has No Alternative

When planning passages, sailors consider intermediate destinations where they can seek refuge if conditions deteriorate. Contributing to the Kobe Bryant crash was a complete lack of preparation or a plan. Once the weather began to worsen, the pilot continued to fly under visual flight rules (VFR) into instrument meteorological conditions (IMC). In this case, the pilot could have sought refuge by landing at an alternate, such as a soccer field or some other safe place.  

4. The Crew Is Unprepared

The skills and capability of a crew may vary. Each crew must know its personal limitations. The pilot in the Kobe Bryant crash continued flight into IMC even though he lacked proficiency in flying on instruments and was not qualified to fly the Sikorsky S-76 in IMC.

5. The Boat Is Unprepared

A vessel must be suitable for its mission. As an example, some boats are not suitable to sail long distances in open waters.

Likewise, some aircraft are not suitable or certified to fly in IMC. The operator of the helicopter in the Kobe Bryant crash was only authorized to fly under VFR. The aircraft was equipped with an autopilot, however, in the final NTSB accident report, there was never a determination whether it was operable. Regarding other safety equipment, the accident aircraft was not equipped with a terrain awareness and warning system (TAWS) or voice or data recorders.

6. Leadership Is Poor

On a boat, the crew looks to the skipper for leadership. In a single-pilot helicopter, the pilot must rely on other resources for support. In the case of the Kobe Bryant crash, the NTSB cited organizational shortcomings and pointed to the operator’s “inadequate review and oversight of its safety management processes.”

7. There Is Excessive Faith In Electronics

Automation dependence is a concern in all modes of transportation. Specific to boats, there is a familiar theme, an “over-reliance on electronics can result in a degradation of basic seamanship skills.”

In aviation, there is a similar concern that automation is degrading manual flying skills. In the Kobe Bryant accident, due to the absence of a flight data recorder, it is difficult to determine the level of automation used before the accident.

8. The Crew Panics After an Injury

Injury to a crewmember on a boat is a distraction and can lead to poor decision-making. This is one area that was not a factor in the Kobe Bryant crash.

However, in a July 2019 crash of an AW139 in the Bahamas, investigators determined that the pilots were likely under external pressure from the aircraft’s owner to complete the flight since his daughter was ill. The flight as planned would have taken family members and friends from a private island to a Florida hospital. The helicopter crashed shortly after takeoff at night with no external visual references—the cause was determined to be spatial disorientation.

Four Rules of Preparation

Lessons from the “Formula for Disaster” fall into four main buckets. These are referred to as the “four basic rules of preparation” and include: prepare the boat, prepare the crew, choose a safe route, and prepare for emergencies.

Translated to aviation, these rules would include the highest level of equipage for each aircraft and the highest level of training for each pilot. To manage all of this, organizations would support the operation with a functional safety management system with the appropriate risk assessments.

Pilot, safety expert, consultant, and aviation journalist Stuart “Kipp” Lau writes about flight safety and airmanship for AIN. He can be reached at stuart.lau3@gmail.com.

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