Ramifications of the Mundane

How Good Crew Resource Management Catches Errors Before Harm Can Occur

By Nat Drew

Nervous excitement abounds as training has commenced for the Aerial Incendiary Operations Supervisors and today is the first day in the air, with a focus on mission pattern and team resource management. As the crisp autumn wind rages around me, I regret not wearing an additional thermal layer. Distracted by the cold, I wiggle my fingers to get my blood to circulate down to my fingertips. I need the dexterity to be able to operate the three cameras I have resting in my lap and fastened to my person. Securely strapped into the seat where the incendiary machine would typically sit, I am posed, ready to capture all the action.

Coming up to the crest of the hills, the helicopter banks slightly to the left as I raise my hands to the camera, ready to capture all the action about to unfold before me. With the doors off, the noise of the rotors and wind is deafening. As we turn the treetops engulf my view and I am dazzled by their rich array of colors, when suddenly, I am overcome with a complete sense of dread. Perplexed by this feeling, I search for meaning….the reason, which I quickly find, as I see my seat belt is undone. I am no longer secured to the aircraft. The gentle turn gazing at the autumn leaves below now feels like a  rally car slamming into a 90-degree bend.

I fumble around with numb fingers attempting to reconnect the seatbelt back together. In what felt like an eternity, but was just mere seconds,  I finally clipped back in. I dart my eyes around the cockpit to see if anyone has noticed my mistake. Am I about to be reprimanded or worse…. ridiculed? Luckily, everyone was concentrating on the mission and no one noticed my mishap.

As we duck down between the hills, the pilot looks over his shoulder to the crew and begins to discuss the mission objectives with the incident supervisor. Again, I raise my hands to the camera, ready to capture all the action. As I lock eyes with the pilot I am again flooded with a sensation of complete dread. My seat belt has disconnected again. Wide-eyed in horror I motion to the pilot as he steadies the aircraft. I frantically fumble for the seatbelt connectors, but the cold wind and the gasping stares of the crew delay my fine motor skills as the metal ends thrash against the frame of the helicopter.

I requested the pilot to find a place to land, one instance of the seatbelt coming unfastened was unusual, but twice. What on earth is going on?

As aviators, we have all been hit over the head by James Reason with his Swiss Cheese model for explaining human failure. Generally, it isn’t just one error/violation that leads to an accident, injury, or death; it’s a sequence of errors, lapses, or violations that, when all lined up in a fatal order, create the perfect environment for one to slip through. Watch any program on aircraft investigation and we see that small, mundane errors line up to cascade into a perfect domino – that can bring down the highest of tech, the biggest of dollars, and the uppermost of skills.

Aircraft accident report history is lined with fallen iPads, a fractured bolt, a piece of poorly placed tape, or simple miscommunication.

Having landed in a grass paddock I assess the situation. Every time I raise my left arm up to my camera, the seat belt comes undone, but why? Earlier that day my colleague had fitted a 360 camera into the cockpit and hit record – we wanted the students to review footage of their mission so that they could see where they could improve. That now seems irrelevant. What I want to know is why was this helicopter so keen to spit me out.

I press play on the footage and the culprit is revealed. It’s me! Well, more accurately the sleeve of my fire jacket. As I raise my hands to the camera the cuff of the jacket gets hooked in the flap of the seat belt, raising it up and setting me “free” (a feeling that is magnified flying without doors).

Reflecting back to Team Resource Management it occurred to me that the holes in the cheese were lining up…Doors off, full aircraft, banking turn, the flapping cuff on my shirt, leading to an undone seat belt. This was all that was holding me back from the brink of eternal nothingness, something as mundane as the cuff of my sleeve. If a few more holes in the Swiss cheese had lined up I could have found myself in a short and sharp freefall.

Back at base, I shared the experience with those around me – people with decades of expertise, experience, and training, and it became apparent that this wasn’t an isolated experience. Others shared similar occurrences of seat belts coming loose by mistake. What did you do? Did you report it? Was it reviewed? Why was it happening? – I asked.

Back to the Swiss cheese with James. We see that an organization’s defenses against failure or errors are represented by the individual slices of cheese. The holes in the cheese represent potential weaknesses or failure points. The system produces failures when all the holes in all the slices momentarily align, enabling the ‘error’ to pass straight through.

For one reason or another, my colleagues each hadn’t reported or actioned it.

In another life, I worked as a Registered Nurse. As a new graduate, the unit manager once said to me “You’re a human, you will make mistakes. The mistake isn’t the problem, it’s when you cover it up or keep repeating it, that’s the problem”.

In nursing, as in aviation, small mistakes can have ramifications if they are not exposed. I didn’t speak up the first time it happened as I was embarrassed. Others hadn’t acted on it in the past as the problem is quickly fixed (and much more a non-event when the doors are on).

All humans will make mistakes. Highly trained and competent people still make mistakes. Human error will occur.

So how gracious will the universe be with me in the future? Will I always be provided the time and opportunity to learn from my errors and faults?

When disaster could happen in an instant, crews need to be able to recognize when the holes start to appear. The quick communication of these ‘holes’ is essential so that an appropriate action can occur. Even when you cannot put a label or name to the issue, if something feels off, such as a ‘sensation of complete dread’ – we need to ‘recognize trigger feelings and language’ as signs of potential harm so that we can divert to a safe location in which we can analyze the situation and react in an appropriate manner to fix the issue.

Nat Drew is a former nurse and current aviation professional working in a government operation in Australia who also writes about her aviation experience and aviation safety topics.

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