It was a sun-dazzled day and the beautiful blue sky was beckoning me as I helped my passenger into the floatplane.
It was a sun-dazzled day and the beautiful blue sky was beckoning me as I helped my passenger into the floatplane. We were departing for a long day of fishery patrol on the west coast of British Columbia, and it promised to be a beautiful day. I finished my walk around and hopped in, pushed off from the dock and the engine started smoothly. I was in great spirits as we taxied a short way up the river in preparation for takeoff. My mood darkened considerably just after takeoff as my vision was blocked by a stream of oil flowing up from the cowling and onto the windscreen. I quickly chopped the power, landed on the river, and taxied back to the dock. The problem? Can you guess? The oil cap had been left off by the engineer who had done some work on the airplane that morning. I had checked the dipstick and found plenty of oil, but had not reached forward and opened the other little door to confirm that the oil cap was in place.
Many people hear stories like this one and with a knowing nod offer their considered opinion of the cause. Complacency. I wasn’t being careful enough. I wasn’t being alert to all the potential dangers.
But if complacency is the cause, what is the cure? How do we combat this dreaded disease? The truth is that complacency is not unusual; in fact it is normal and natural for humans to become complacent. We all become complacent and it happens very easily. Now before you rush to string me up for heresy, let me defend that statement.
How often do you need to do something before you consider it extremely safe? If you do something 10 times in a row, and nothing bad happens, it starts to feel safe. Do it 100 times with no ill consequence and you start to feel pretty comfortable. Do it 1,000 times and you would laugh at someone who told you that it was dangerous. And yet in aviation, something that can cause a problem just one time in 1,000 is still 1,000 times more dangerous than we would want. We want people to be alert to risks that are so unlikely that if they flew 10 flights a day, 365 days a year, for 50 years, they still might not encounter the problem. Trying to maintain vigilance in the face of such a threat is not easy. In fact, it is almost unnatural.
Of course, I had been trained to check the oil cap on a walk around. And I believe I have checked the oil cap on every walk around I have ever done. But after thousands of flights, without ever finding the cap in anything but its on and locked position, something deep in my subconscious probably relegated that check to the category of “it’ll never be a problem.”
So please don’t shake your head and grumble about complacency when you hear about a pilot who makes this kind of error. Rather, ask yourself what you are doing about complacency. The only way to fight complacency is to keep yourself educated about the risks in your flying. Keep reading accident reports. Attend safety briefings. Make note of your own errors after each flight and make a point to learn from them. Little things happen in every flight and they provide an opportunity to learn free lessons. Even so, it probably won’t be enough. Our brain just isn’t wired to stay alert to such minute possibilities.
You need to participate in a larger pilot community or organization so that as a group you can communicate incident reports, hold safety meetings, and keep talking about the things that could go wrong. Your organization is exposed to far more opportunities for error because there are many more of you flying. Therefore it is quite likely that someone in your organization learned a lesson today that might save you some grief down the road, if only you could learn about it. If you are not actively communicating lessons to others, and learning from them, you are missing out on opportunities. If your organization is not actively working to maintain vigilance, complacency will happen.
We cleaned up the cowl and the windscreen, replaced the oil that was lost and triple-checked that the oil cap was back in place, and off I went on a beautiful day of flying. But despite a really good clean-up job, a couple of thin black streaks made their way up the windscreen during the course of that day. They were a good reminder that it takes a determined effort, and the help of the whole organization, to keep complacency
Gerry Binnema has been in the aviation industry for 28 years, as a pilot, AME, accident investigator and safety officer. He has spoken at numerous conferences and provides training and consulting in SMS and human factors. Visit his website at www.gjbconsulting.com or e-mail him at firstname.lastname@example.org.
This information is intended to increase overall safety awareness and is not a substitute for compliance with regulatory guidelines.
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