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Risk Has No Memory

Don’t Open the Door to Error, Safety Has no Safecuts 

I was sitting in the cockpit, waiting for the ground crew to fuel my plane. Right then a pickup truck arrived with a hard stop, dragging its tires. Its driver jumped out and rushed to me. His eyes were bloodshot (not to say in tears) and with a crop map in his hands he said to me, “Please save my farm. I’ll pay whatever you ask”.

This shows that we pilots, ground crew and especially ag operators should not have excuses. We sell application services, farmers depend on us because often we are their last hope, as we can make the difference between a successful crop or its total loss. For all this, we must do our job.

However, not having excuses does not mean we have to accept every job and say “yes” to everybody. Our limitations are based on predefined protocols and procedures.

Procedures, protocols and rules have been written in blood

This reads a little dramatic, like something out of a movie. However it is true. In aviation you either learn from your own mistakes or from someone else’s. That’s the reason for hangar talk, mentors, an infinite number of videos and articles like this.

When we talk about history written with blood, we mean aviation itself. How many errors, accidents and fatalities are the cost of our learning. All those failures have been incorporated in the procedures for a safer aviation.

Registering events

In order to certify an ag operation, Uruguay requires its adherence to the Safety Management System (SMS) and that it registers any safety incidents. Registering safety incidents is voluntary and does not entail punitive actions. This means that any incident that happens in the operation and that does not conform to the Aerial Applications Best Practices should be reported voluntarily. The other keywords are “does not entail punitive actions”. If I admit that I made a mistake, what will happen to me? We should impart in our companies a collaborative environment and adopt continuing improvement practices so that we all can recognize our errors and learn from them. The events to be reported may range from simple to serious, depending on their potential to affect safety.

Risk has no memory, don’t play victim and don’t “live with error”

USAF Colonel Mike Mullane (former NASA astronaut and a guest in Air Tractor’s Turn Smart video, https://www.youtube.com/watch?v=gKP41xZQQgU&t=1834s) speaks about the dangers of the  normalization of deviance and how this relates to ag aviation. I took three main concepts from it: don’t play victim, know that risk has no memory and more importantly, don’t get used to pushing the envelope while expecting you’ll always get away with it.

If I make hammerhead turns believing I’ll finish a job earlier, if I give in to the pressures of farmers to fly in any conditions, if I accept to fly with an inoperative system and I get used to this, all these situations have an impressive technical name, “normalization of deviance”, or in the simpler words I use to call it, “living with error”. Risk has no memory, I can live with an error one, two or ten times, possibly in the eleventh time I’ll end up in a crash. Why? Because risk has no memory, abnormal situations are exactly that, abnormal. And making them routine does not reduce their potential for catastrophe, just the opposite, it increases it. And after the crash comes the worst part, to live with its consequences. Many then play victim, saying, “why did this happen to me, I have thousands of hours, I’ve done it that way all my life”, and so on.

Give yourself some room to deal with the unexpected 

I’m speaking for myself, but it certainly happens to many of us. How many times do we feel the need to stop, think and ask ourselves, “Why am I doing this? What’s the reason for this unsafe way to operate? What do I get by living with an error? Whom do I want to please with this?” The difference between humans and animals is what experts call self-awareness. That little inner voice that tells us, “wait, there’s something wrong, stop doing that”. The other option is to act by instinct, like animals do.

That’s the reason why, one way or another, all pilots should have some training about dealing with external pressure, and we all should know our company’s policies about it. Evidently, there are situations in which circumstances force us to give in and push the envelope a little (it would be hypocritical not to admit it), however this shouldn’t become the norm.

We should always expect failure, error or the unexpected and give ourselves some room to deal with it, in order not to have to regret our unpredictability. A good exercise is to “fly ahead” of the airplane, I mean, to figure what will happen, the corrective actions to take and then to focus on the flight phase I’m in.

Concorde pilots (the most complex to fly commercial airplane in the world) had to fly 200 miles ahead of the airplane, to avoid surprises. I’m not asking for us to fly like Concorde pilots, but we can be proactive, take our time to think and assess, register our errors and the most important, not live with errors.

Our goal is not having to face the worst situation a pilot may experience, crashing a plane – if he survives to regret it.

For we should control what is inside our influence circle; there’s no excuse for not fixing what is broken, not replacing a bad procedure and not knowing when to stop.

No matter if a farmer goes to your airplane in tears and asks you to save his crop, sometimes we have to say no. If we open the door to the “normalization of deviance”, we should know that “risk has no memory”.

I’d appreciate your feedback on my articles – mporto1@gmail.com

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Martin da Costa Porto is an ag pilot and ag instructor in Uruguay. He has over 25 years and 12,000 hours flying ag, besides 3,000 hours as a flight instructor. Presently, he runs his own ag operation in Uruguay.





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