Tuesday, April 2, 2013

Three strikes ...

Deb and I have been dissecting the sailing book I mentioned a few posts ago trying to decide what we might have done different. And, as these things are want to do, another of the blogs she follows initiated a spirited exchange in its comments section about the very same subject ... risk management and accident chains.

There are many who suggest that all accident chains have at least five links. I don't know that that is a hard number. More likely it is an aggregate sum that works out well in Power Point presentations used in safety seminars. But it is as good a number as any. Here is also a good time to remember that we are contemplating accidents that are truly accidental. If one gets hammered, then climbs aboard a 150HP super bike and blasts off into rush hour traffic, that accident chain has but a single link. The resulting carnage is mostly a forgone conclusion resulting from near suicidal stupidity. The first step to breaking an accident chain is to remember that a colossal act of real boneheadedness can get one killed without any additional links needing to be forged.

Working to avoid accident chains in my aviation life means any airplane that has me sitting in one of the two front seats is working on a three strikes rule. One thing goes wrong, no matter how apparently minor it is, and we have a strike. A light quits working, a gauge gives me a wonky reading, the weather we are seeing out the front window is noticeably different than what we expected from the forecasts, it doesn't matter what it is so long as it is a thing unexpected. Since I almost always fly as part of a crew any such incident is immediately shared and we start thinking specifically as to what kind of threat this may portend.

Aviation is a dynamic enterprise and, truth to tell, unexpected things occur on a lot of flights. Often it involves the weather. Forecasting is much better than most of us like to admit, but it is still an inexact science and sometimes they get it really, really wrong. Or the unexpected thing might be an equipment problem of some kind. It is almost always nothing more than a minor annoyance with multiple systems and back-up options at hand. A lot of flights reach the destination with a single strike being assessed, just another day in the office.

On rare occasions a second unexpected thing will raise its head and demand our attention. It is almost always a thing completely unrelated to the first thing. Occasionally it appears to be unrelated but, as the flight unfolds, the two get intertwined. An easy example is a much higher than anticipated headwind followed by an unforeseen route change from ATC. The extra fuel we put on board for "Mom and the kids" is suddenly not so extra any more. In all likely hood we still have plenty of gas, but we also have two strikes. I have been doing this a long time and have often carried on to the original destination with two strikes on the score sheet. It is also just another day in the office, but a day with the gremlins out playing. We will be keeping an extra eye out for their games.

Now, still using the example above, add a third thing. It might be related; say a fuel gauge going weird or an oil pressure starting to fade a little. It might be completely unrelated; a radio quits working, one of the navigation systems takes a break, or a generators goe off line. What ever it is, the destination now becomes the nearest suitable airport. It doesn't matter how unrelated the unexpected things appear to be. It doesn't matter how badly the Bosses in the back of the plane need to be where we were originally going or how dear to my heart it is to get home in time to see my Daughter in the school play. There are three strikes and now the assumption is that this flight might be an accident looking for a place to happen. It might not be, but there is nothing to be gained by pushing on to see what happens next. Meetings can be rescheduled, there will be another play.

Such a stop doesn't necessarily mean we are done for the day. A couple of hundred pounds of gas can cover a ton of weather concerns. A quick review of a gauge reading by a mechanic might reveal, for true and for sure, that there is no real problem with the system and continuing on is a prudent thing to do. But we stop and figure it out in a safe harbor where we know we can't get hurt. And we don't leave until the strike list is back to zero.

I have to admit that I haven't worked out just how this applies to living on Kintala yet. Airplanes fly for scant hours at a time and a divert destination is never that far away. Going anywhere in a sailboat takes days, weeks, or months. The nearest place to go just might be the place were one is already going. So maybe, when an unexpected thing rears its head underway, the proper response is to fix it, get it off the list, and keep on going. Low on fresh water and days from shore? Fire up the water maker or find some rain to collect - problem solved - continue on. Unsure which way a distant storm is going to go? Take up a heading sure to be away from its path until it shows its intent - problem solved again - continue on. Sail torn, block not working, line nearly chaffed through? Don't wait. Fix it and get it off the list. The point is not letting the "strikes" accumulate. (Fixing things in route is not usually an option up in the flight levels. When it breaks up there it stays broken until we land.)

The strike list doesn't suggest that we always take off with a perfect airplane, leave port in a perfect boat, or always wait for a perfect forecast. In the jet we have a thing called a Minimum Equipment List. It is exactly what it sounds like, a list of equipment allowed to be broken yet we can still depart on a trip. Very often the list details some procedure that the crew must adhere to to compensate. We might leave with a landing light burned out as long as the flight will land before dark or a seat belt not working so long as that seat is blocked from being used. The destination weather might be sucking giant lemons, but if we know that before departing it all becomes part of the plan and, as such, is not a strike. Strikes are things that were not in the plan. Letting them accumulate is watching the accident chain get longer.


Latitude 43 said...

Good post.
The same rule applied to manufacturing. Equipment failure most often occurred in steps, leading to a total breakdown, or bad product. A good engineer could piece the events together, predict an outcome, and take measures to prevent the breakdown. Not recognizing the events as a precursor to a bigger problem often leads to costly recovery and preventative measures after the fact.

A sailing example? I can offer an issue I have right now as an example. Not recognizing the raw fuel in my exhaust, and the white smoke on start up as an injector problem, could lead to an engine issue as you are navigating a tight entrance to a harbor. This could be disastrous, but I recognize the signals, and will swap injectors to insure reliability. What if I was out there, on the water and recognized this issue? I would avoid the tough entrances, and be prepared to sail at any moment, which you should be anyway.

On the way down here I had dirty fuel issues that stalled the engine a few times. We were lucky it happened in open water. Were there signs previous? Sure. We had a wild sail on Lake Ontario before we left, and the engine sputtered a bit on our return to the slip. Basically all the muck in the tank stirred up and clogged the filter. I changed the filters, bought a dozen more, cleaned the fuel as best I could, but apparently not well enough. A complete tank cleaning and fuel polishing was required, but we were running out of time, and had to leave. Bad on my part, as I failed to realize the bad situation this could lead to.

So, does accident prevention start with you? Absolutely. Be attentive, recognize the abnormal.

My best advice would be not to rush. Take it slow. How many times do we get into trouble because we did not take the time to understand the situation, because we wanted to be somewhere at a certain time. I see people leaving in fog, high winds, darkness, things not working properly, etc. because they want to be somewhere at a certain time. There is a definite "beat the crowd" mentality out here. Maybe it's just an ICW thing.
We plan on taking it real slow. Nowhere to go, nowhere to be, Except when we're under sail, because fast is fun :)

Thanks for the good morning read.


Velero Amande said...

See some times pressure of daily life, makes sailing one of the most satisfying and relaxing activities you can do. Sailing is not about getting someplace fast. It's about enjoying the journey..we enjoyed it in Velero Amande sailing in San Blas more than any other medium .