Editor’s Notebook: A Beacon for Safety Efforts

By By James T. McKenna | October 1, 2006
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A bright spot has come on the scene of the struggle to improve helicopter safety. I’m betting this beacon will help guide us through the most difficult safety challenges we face.

Those challenges center on the role of the human in accidents and mishaps. There are other challenges—single- point failures in critical aircraft systems, for instance. But the human role is the crux of the problem.

It is conventional wisdom that human error is a major causal factor in about eight out of 10 helicopter accidents. On the surface, that seems obvious. Many accidents seem to boil down to a matter of someone having “screwed the pooch,” as Tom Wolfe captured it in his classic, “The Right Stuff.” Those who don’t screw the pooch have the right stuff to be pilots. Those who do lack it.


Aviation long operated on that assumption. Find out who screwed up, bury them—dead or alive—and move on.

The problem is that this approach goes only so far toward improving aviation safety. It attacks the symptoms but not the root problem. Take, for instance, the findings of an August 2005 Robinson R22 crash in New Zealand that killed the pilot and seriously injured his passenger. The CAA found the tail-rotor drive shaft had failed, causing the crash. Two unlicensed mechanics had assembled the drive shaft incorrectly. One licensed mechanic signed off their work without observing or inspecting it. Another assisting him knew that, the CAA said, but didn’t raise an alarm.

Now these seem to be four people who screwed the pooch. We could make a strong case that they’re to blame. But how did that happen? How did two licensed airmen and two others get to the point where they individually decided that doing things wrong was all right? You could throw them in jail. You could yank the two licensed mechanics’ tickets forever. But until you answer the question, “Why?,” you can never hope to prevent similar errors from killing someone again.

Why can’t we be satisfied with figuring out who’s to blame and getting rid of them? Helicopter Assn. International President Matt Zuccaro offers the most compelling argument for why we can’t. The cost we all pay for rotorcraft’s high and chronic accident rate is not just in the lives lost or maimed and the aircraft destroyed or damaged, he argues. It is also in the helipads and heliports we can never hope to get approved, the routes we’ll never be able to fly and business we’ll never win because too many people simply don’t trust helicopters.

Don’t agree? Consider Scottsdale, Ariz., where local government has passed an ordinance banning aircraft takeoffs and landings; it is aimed at helicopters. Scottsdale’s city planner explained that the handful of residents who have helipads can keep them legally; they just can’t fly helicopters to or from them. That law might only prevent one or two helicopter sales. But that’s just one town out of hundreds of thousands in the United States alone. The numbers can stack up, and you might never know what you lost because they did.

So we can surrender to the sentiments that drive such measures or act to secure new public confidence in rotorcraft. The first step in doing the latter is accepting the need to find out why accidents and mishaps occur. Which brings me to that beacon.

It is Robert Sumwalt, who on Aug. 21 became the 37th person appointed by the president to oversee the U.S. National Transportation Safety Board. He was immediately named the board’s vice chairman.

Sumwalt is a fixed-wing guy, a 24- year airline pilot. But he worked for many years as an accident investigator and safety leader for the Air Line Pilots Assn., and he’s an expert in human factors. Now you may have your views on unions in general and that one in particular. But one thing ALPA has done to all our benefit has been to discredit the “screw-thepooch” school of safety.

For decades, ALPA challenged the safety community to go beyond blaming someone and explain why a string of events joined into a lethal chain, of which the human was the last link. That led to revelations of—and fixes for—design, system and procedural flaws. It also has led to the development of human factors as a key element of accident investigation and aircraft design.

Helicopter pilots haven’t benefited as much as airline pilots from that trend. They largely work in the military or in small outfits. They’re not organized as a labor or professional group, so they don’t have a unified voice in challenging charges of screwing the pooch when it comes to accident investigations. Equipment makers and operators are more unified and powerful. One result, I’d argue, is that statistics on helicopter accident causes are probably weighted a bit heavier toward human error.

If true, that’s not just a problem of fairness. It means investigations have been satisfied with findings of human error while deeper, more obscure system or design flaws were left to persist and cause other accidents. As long as we stop at the human error, we can never hope to achieve the safety advances needed to win public confidence.

I’m not saying Sumwalt will be an apologist for pilots at the NTSB . But he will prod the safety community to get behind what happened and explain “where was the rest of the system that should have prevented a simple error from becoming a catastrophic incident,” as he said at a later, public swearing-in. “The discovery of the human error should be considered the starting point of the investigation, not its end point.”

Such an approach can only benefit us all.

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