Safety & Health Effects of Shift Work - ASSE Members

ACCIDENT INVESTIGATION
BY JEFF “ODIE” ESPENSHIP
Approachability:
The Last Domino
Nearly every supervisor in the workplace feels they
can be approached by others, but are they really
“approachable” What does “intervening” in the
workplace mean to you as a supervisor or foreman
What does it mean to the one being supervised
This article examines the final moments of three
aviation accidents in an attempt to get at what makes
approachability in the field so difficult. How can we
become more approachable from the bottom up, from
the top down and from peer to peer
When the dominoes begin falling, accident investigations
often reveal that someone on the job could have
intervened with a critical piece of information but either
did not speak up or was not listened to.
The purpose is to not pick apart each falling domino,
but simply to look at the final moments, the end game,
“the last domino”—approachability.
Reflect inward and ask yourself, what does “approachability”
really look like, sound like or feel like in the field
What you may find is that being approachable and intervening
on the job is not as clear cut as you might think.
•Air Florida Flight 90: crashed into the icy Potomac
River in January 1982 (74 fatalities).
•Comair Flight 5191: departed from the wrong runway
in Lexington, KY, in August 2006 (49 fatalities).
•PanAm and KLM 747 crash on the island of
Tenerife: worst aviation accident in history in March
1977 (583 fatalities).
In each example, the pilots (workers) had the power
to stop the work before disaster but failed to do so.
Why
Let us look at the final dominos of Air Florida
Flight 90.
COCKPIT VOICE RECORDER TRANSCRIPT
Co-Pilot: God, look at that thing. That don’t seem
right, does it Uh, that’s not right. (Referring to engine
gauges)
Captain: Yes it is, there’s 80. (Referring to airspeed)
Co-Pilot: Naw, I don’t think that’s right. Uhhh,
maybe it is.
Captain: 120. (Referring to accelerating airspeed)
Co-Pilot: I don’t know
Now barely airborne, the sound of the “stickshaker”
(warns pilots of impending stall) heard continuously
until impact.
Captain: Stalling! We’re falling!
Co-Pilot: Larry! We’re going down, Larry!
Captain: I know it!
When employees in the field are unsure of what they
are seeing or experiencing they either will not speak up
for fear of looking stupid, or if they do speak up (which
is the case with Air Florida), they may not be able to
articulate exactly what they can or cannot see. It is difficult
to clearly explain a bad feeling you are having, especially
to a supervisor. So beware, approachability in the
workplace may look or sound something like:
“Hey, this doesn’t seem right, does it”
“This light is, uh, isn’t this light usually off The
power is off, right”
“These uh, are these the right fittings for this pipe”
Be on the lookout for the rhetorical question, the
vague statement or the unsure utterance. It might be your
last domino.
In the Comair Flight 5191 accident, three experienced
pilots in the cockpit departed from the wrong runway in
Lexington, KY, in August 2006, which resulted in 49
fatalities.
It is early morning and still dark out as the captain
taxis the airplane to depart on Runway 22 (Figure 1).
Instead, he mistakenly turns onto Runway 26, a runway
that is too short for the required takeoff roll. How could
this happen to a highly experienced captain at the tiller,
to a normally alert co-pilot sitting next to him and to
another pilot sitting in the jumpseat
Be on the lookout. Approachability might not come
from a person, but from the job itself. We fail to act on
numerous nonverbal hints and clues when working. It
might be a missing part on a machine; a broken wire;
equipment behaving strangely; or lights that are normally
on are off. The Comair Flight 5191 crew was no different.
Runway 26 had no runway lights on, which Federal
Aviation Administration regulations require for night
operations. The runway itself was attempting to tell the
crew that something was not right.
As the crew began the takeoff roll down the unlit,
darkened runway, approximately 12 seconds into the
work, the first officer said, “That is weird with no lights.”
“Yeah,” confirmed the captain. No response from any
crew member again until 15 seconds later. The captain
exclaimed, “Whoa!” as the end of the short runway
appeared. The sounds of the crash followed shortly
thereafter.
As we read this, we might be thinking, “How could
they be so stupid Why didn’t the pilots stop” Intervention
is not always cut and dry.
Situational awareness is the measuring stick for our
perception of reality versus actual reality. Taxiing an air-
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Safely Made www.asse.org 2011