I flew back safely from Finland on Saturday – or I should say British Airways and American Airlines flew me safety, including in the 747 pictured at left. 15 hours across three flights. It was a long day. But, I wasn’t really worried about my safety because of the great track record that the aviation industry has demonstrated (and taught to industries like healthcare).
That said, mistakes still happen. We’re all human. But, what does an industry do and how do they react when a mistake is made? Recent events with a British Airways flight are telling.
As reported May 25: “BA Plane ‘On Fire’ As It Flew Over London.” See also this picture. Some people initially jumped to the conclusion of “terrorism” (which serves as a good reminder about not jumping to conclusions when problem solving).
From that initial report:
“The airline has begun a full investigation into the incident and is working with the Air Accident Investigation Bureau to establish the cause.”
Unlike medical errors (or “adverse events” or “sentinel events”), which are generally underreported, a burning plane over London is a VERY visible problem. The public demands answers and investigations. In healthcare, people might say “well, nobody was hurt” (which is true in this BA fire incident… the plane landed safely, but I’m sure it scared some people).
Within a week, explanations started coming out in the news. With my Lean hat on, I’d hope and expect that the aviation safety experts and the airline would be looking for process improvement opportunities rather than just “naming, blaming, and shaming” an individual or two.
I had four different British newspapers with me to review on the trip from London to Dallas/Fort Worth and they all had coverage of the BA plane fire.
This headline seems to ascribe blame:
A passenger aircraft was forced to make an emergency landing because BA maintenance staff failed to secure engine covers after routine servicing.
So the fact appears to be that engine covers (on both engines) were not secured (latched) properly.
But rather than asking “who messed up?” we could ask “why did that occur?”
The failure by staff at Heathrow to complete standard safety checks resulted in a near-catastrophe in the London skies last week, accident investigators revealed yesterday.
The phrase “failure by staff” is a collective blaming. Sure, somebody (or bodies) didn’t latch them properly. Did somebody also not double check? What are the standard procedures? Why did this not happen? How often does this error occur?
This article focuses on the lack of inspection:
Failure of ‘walk-around inspection’ blamed for British Airways’ Heathrow emergency landing after engine caught fire
One reaction from the British government:
…the Air Accidents Investigations Branch (AAIB) rushed out a report urging airline ground staff and pilots to check that the engine panels are properly closed before departure.
In healthcare, my experience is that asking staff and surgeons to be careful and double check things doesn’t always work… unless those checks are built into a checklist that’s used and verified 100% of the time. Being aviation, this guidance might be more effective than it might be in healthcare, but it begs the question about why this check or inspection wasn’t being done before.
Airbus stresses that the pilot conducting a walk-around “must be positioned on the side of the engine and crouch” to make sure the panel was properly closed.
So why wasn’t that done?
The AAIB stresses that the sole objective of its investigation is to prevent future accidents, not to apportion blame. But the interim report indicates that engineers failed properly to close the panels; that the pilots did not spot the error during the “walk-around” inspection; and the problem was also missed by the push-back crew.
It’s not unusual for aviation to emphasize blame-free investigations with a focus on preventing future occurrences.
The above quote also goes to show how errors often slip through because multiple points of inspection fail (perhaps one person thinks the other will catch a problem, so, being human, we let our guard down, especially if a certain problem rarely occurs).
And this article had some other detail:
There’s a bit of blaming:
It is understood that an engineer who performed scheduled maintenance on the aircraft overnight has admitted to failing to secure the latches.
There’s a bit more systemic “why?” involved:
During preflight preparations the standard practice is for at least one of the plane’s pilots to inspect the aircraft externally. On the engine covers of this type of aircraft, however, the inspection is difficult because the latches are positioned below the engine, which has a clearance of just two feet (60cm) off the ground. The AAIB report said that an engineer normally needs to lie on his or her back to secure the latches.
An engineer “blundered” but so did the pilot for not catching the problem. But, the engine was designed in a way that makes inspection “difficult.” Does the airline make it easy for a pilot or engineer to lay down on the ground? Is there a pad or a mat? Or something like an auto mechanic would use (it’s, strangely, called a “creeper.”)
It’s hard to assign a single “root cause” to a situation like this, eh?
What are some possible countermeasures the airlines could take?
- Ask Airbus and/or the engine makers to redesign where the engine cover latch or, at least, its location.
- Make sure the pilot checklist has this inspection step and have senior leaders verify proper use of the checklist.
- Add a sensor or interlock that alerts the pilot in the cockpit that the latch isn’t closed proper (like a car’s “door ajar” warning).
- Punish and fire the engineers and pilots involved in this incident.
What would you do? It’s unclear exactly which action or actions will be taken by the airline (although, thankfully, blame and punishment seems unlikely).
Jock Lowe, a former director of flight operations at BA, praised the response of the crew to the emergency and said it was clear that human error was to blame. “Unfortunately, as long as we have human beings in the loop, mistakes will occur,” he said.
He added that it would have been difficult for the crew to spot the maintenance blunder because of the position of the latches but conceded that was what a visual inspection was designed to do. “Perhaps one of the pilots should have picked it up.”
About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as the new Executive Guide to Healthcare Kaizen. Mark is also the VP of Innovation and Improvement Services for KaiNexus.