Safety & Health Effects of Shift Work - ASSE Members

Figure 1
Blue Grass (LEX)
Airport Diagram
plane onto the correct runway can be perceived as a lowrisk
event. Pilots always get it right. This perception
lured all three crewmembers into a trap; they failed to
verify the correct runway. Now, their perception of reality
is lethally different than their actual reality.
The lack of runway lights was trying to intervene, but
the pilots failed to listen. Why Simply because when
hints, clues or suggestions from our surroundings begin
to show us that actual reality is different from our perception
of reality, it is human nature to rationalize away
and to not listen. The Comair crew knew construction
was underway at Lexington airport. Perhaps the runway
lights were off for that reason We will never know. We
do know they continued the takeoff, wanting to maintain
their perception of reality as being real. In these cases,
we want to be right, but if the job is hinting that “something
is not right,” listen to the clues. It might be your
last domino.
The final accident is perhaps the saddest. It stands
today as the worst aviation accident in history. Five hundred
and eighty-three people lost their lives when two
747 Jumbo jets collided on a fog-enshrouded runway
at Tenerife island in March 1977.
I personally interviewed Capt. Robert “Bob”
Bragg, the only surviving pilot of this tragedy.
Capt. Bragg was the co-pilot onboard the Pan
American 747 airplane when the KLM 747 emerged
out of the fog, at more than 150 mph, in an attempt
to take off. It failed to get airborne high enough
and slammed into the top of Capt. Bragg’s Pan
American jet. I asked him to listen to the cockpit
transcripts of the KLM 747 crew and to discuss the
final dominos.
KLM Captain: We’re going.
KLM Engineer: Is he not clear then
KLM Captain: What do you say
KLM Engineer: Is he not clear, that Pan
American
KLM Captain: Oh yes (emphatically).
In reference to this transcript, Capt. Bragg said
of the KLM captain, “I think he got in too big of a
hurry, trying to get back on schedule. He mistook
his route clearance for a takeoff clearance. He then
failed to listen to his engineer.”
Being in a hurry on a foggy runway and misunderstanding
the control tower led to degradation in
overall cockpit situational awareness. The overbearing
captain (supervisor), with a new co-pilot (new
hire) and an unsure engineer (peer-to-peer) made a
complete recipe for workplace disaster.
This tragedy laid the foundation for cockpit resource
management for airline pilots. The lessons
we have learned is now applied to businesses around
the world.
Bottom-up approachability can be difficult for
the one who feels threatened or intimidated by
another’s experience, skill and knowledge. Supervisors,
actively listen when others have questions. It
might be you who is mistaken. No one wants to look stupid
in front of the boss or peers, so be sure to thank
those who have the guts to bring up concerns. Take the
time to listen to ambiguous, odd or vague statements.
This encourages open communication. Ask probing
questions. Make sure everyone has a high level of situational
awareness. Never assume. Lastly, watch for clues
from the job itself. It might be a light, a switch, a piece
of equipment, a tool or a procedure that is speaking up.
It is always better to slow down and spend a few seconds
of your life than to lose your life in a few seconds.
Jeff “Odie” Espenship is the founder of TargetLeadership. He
holds a bachelor’s degree in Political Science from the University
of Georgia and participated in the Air Force ROTC program. After
6 years of service in the Air Force, Espenship became an airline
pilot. He began his career with Delta Air Lines in 1992, where
he currently flies international routes out of Atlanta, GA. Amid
his tenure as an airline pilot, Espenship also flew a 1943 T-6
“Texan ” on the airshow circuit. A tragic accident took the lives
of his brother and a pilot. This event led Espenship to create
TargetLeadership.
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Safely Made www.asse.org 2011