Plastic Pilot

Aviation is an extremely regulated industry. Not commercially, but legally speaking. The duties of operators are very well defined, including in terms of incident reporting. And because all airlines are doing the same business, the whole industry can benefit from lessons learned by any actor.

This may sound like theory, but it’s really common and daily practice. Incidents are reported to various authorities on a very regular basis, and information is reduce to minimize any potential hazard to its minimum.

Principle illustrated by Qantas - Could have been any other airline
The Qantas maintenance in Melbourne gave one more good example recently: months ago a new oxygen cart has been delivered, to be used to refill airplanes emergency oxygen tanks. The plugs did not match the planes, so the guys replaces them…

Months later (sic!) and engineer doing something completely unrelated noticed two employees topping-up a plane oxygen reserve with this cart. He asked them why they were doing it with a nitrogen cart (double sic!), which he was the first to identify correctly. The plugs were incorrect, because they were standard for nitrogen, not oxygen ! One can certainly discuss how it has been possible to replace the plugs with no one noticing the difference, but this is not the topic today.

In the same situation, what would YOU have done ? Just look in another direction, whistling a silly song, and make sure no one caught you ? Not only the Qantas guys did correct the situation, but they also reported it to authorities and to all potentially impacted operators ! Can you imagine the kind of courage they had ? Looking somewhere else is sooo easier. This kind of reaction is only possible when safety culture is strong. The only criminal behavior would be to do nothing !

Facts, causal factors and mitigation - Not responsibility and punishment
As any incident, this one has been documented and the report has been transmitted to all potentially involved stakeholders, and to the whole aviation community, plus media. It even went out in Australian newspapers. The fact of publishing all information may sound surprising, but it is the way things are done. Can you imagine hospitals, or nuclear facilities publishing all incidents ? This is how aviation works. As all airlines do the same thing, they all have to learn…

Another key point in this safety culture is its non-punitive aim. The purpose of incident reports is to establish the facts, find out contributing factors, and possible mitigation procedures. Full stop. Responsibilities and guiltiness is a question of justice, not incident investigation. To promote reporting systems, many companies and authorities offer anonymous reporting systems !

Being legally protected, nothing could refrain employees to report incidents. This is particularly true for incidents which by luck have no consequences. If reporting such mistakes could lead to punishment, no one would report them… and no lessons could be learnt.

Protect safety - protect you
Promoting a safety culture is extremely hard work… especially in our world where lawyers and media are so prompt to judge everyone and everything. When aviation people will stop reporting and start looking away, I’ll start travelling by train ! But this is not the day… yet.