25 Oct 2021 21:38


By: Sergio Romero

“You don't need a patch on your arm to have honor.”

Lt. Kaffee. Film “A Few Good Men”

One of my mate investigators read my accident report. He went back and forth through the document and hit me with this statement: I feel this is a good document, but erase the portion wherein you tell us you guys did not receive a proper support from the boss! The truth can be profiled by as much filters as possible, but it will always remain attached to the root cause. A coin has two sides. And this applies also to the truth, we were taught about it. But what I felt after investigating this aviation accident, among others, was that there are indeed two sides for the truth. One of these is the real, raw and valid side. The other one struggles to hide the contributing factors or the latent conditions. Thus, it is a space for concealing, misleading and even telling a blurred story.

Two weeks before, I was deplanning the jet with my colleague and friend. A big and modern city in my country. I had been there before for a Safety Roundtable just six months ago. That time of the year I felt a heat surge on my face. 30 degrees Celsius mean no difference between day and night. These days are featured by heat, moisture, raining and IMC flights in the mornings though they were filed as VFR. What would have happened if these conditions would have been analyzed with the IS 9001:2015, specifically clauses 4 and 6? Unfortunately this happened a long time ago. These were times of the ICAO’s Doc. 9422; the Accident Prevention Manual and IS 9001:2000. We were trying hard to disseminate HF training all over the country. We did the R&D well. One of our colleagues even travelled to Canada at his own expenses and brought us the HPIAM Training CD. It was like giving a child a candy, tender and sweet, but right on time? I guess not!   

What did we bring for this accident? A checklist we made based on the HFACS model, our milestone planning, and hard copies of the regulations. It was our first deployment and we were told to just apply the rules and everything will run properly.

Walking down the street that leads me to the airline headquarters, I regret to behold this scenario: All bars close to the airport crowded by men with cameras and microphones. They look exhausted and the doubt was all over them. It was a mined path to the Flight Operations Manager’s office, but we made it! 

Despite all these years, I still remember my dialogue with this flight operations officer. My questions tried to determine the environment or safety culture wherein the operations had been performed. So, the questions were specifically aiming at:

An astonishing background silence could be heard in this office. The flight operations officer was quite nervous and insecure when he confessed this to me: Sergio, we had some problems with this captain. I’d rather say plenty of times. But he was so good when flying that we had to omit his problems. Tell me about his problems, I added. Well, you know. As I told you, he had an oustanding flying performance. Very precise and accurate. But we had to deal with two issues regarding this pilot. Regarding the first one, he told us he needed at least 1,000 USD a month for his family. So, even though he had not flown enough hourswe needed to send his family the required amount of cash. So, he was owing us some money, but as we trust him, it was a good deal. Regarding the second issue, I had regretfully to recognize an issue with his attitudeHe was running wild into everything he considered an obstacle. No one could do anything about it. I mean denials were not for him. I knew no surge should come from me in this interview, even when listening to this. What did you guys do about these problems? I asked. Did you talk to him, did you report this to the CEO? Did you initiate a behavior monitoring?  

Well, Sergio, doing something about this would have this meaning: We would have to let him go! I mean he would have lost his job! It was the first accident I was assigned to investigate. And taking this into account, I threw my dice. What about you guys now? This pilot lost his life like the occupants of the airplane. What can we tell to the relatives? What can be done about the sorrow and tears? And this is not the only issue here. It’s not only about the pilot that was killed in this accident. He lost his life, and you probably will lose your airline.

Some years after this accident, I was working for another airline in my country. And this same air carrier stroke back with two more accidents. Could it be said they learned something about safety, management, prevention and planning? Have you heard this statement: If you keep doing the same actions, why do you imagine you would become a different result? Some time after, the airline went into bankruptcy, just like the lives that were lost and the business they built. What about the safety culture that I detected? I strongly believe that if some air carriers keep on sending machines to fly to 4,000 feet or more right to the space without planning, risk management, no traceability of components and a poor accountability, what would be the results? This way makes quick money in the first place, but not safety, not even in the last place. I’m reminding now Senator Maria Cantwell words before the US Congress: “…one thing is crystal clear: If you want to be the leader in aviation manufacturing, you have to be the leader in aviation safety. But we cannot have a race for commercial airplanes become a race to the bottom, when it comes to safety. The company, the board, cannot prioritize profits over safety”.