Five months in jail (and PTSD) - pilot found criminally negligent fornot following a preflight checklist

[son_of_flubber]

http://www.ctvnews.ca/canada/hang-glider-pilot-sentenced-to-5-months-in-jail-over-fatal-tandem-accident-in-b-c-1.1681084

[Sean F (F2)]

Frankly I agree with the ruling.

[brianDG303[_2_]]

On Thursday, February 13, 2014 9:49:06 AM UTC-8, son_of_flubber wrote:
> http://www.ctvnews.ca/canada/hang-glider-pilot-sentenced-to-5-months-in-jail-over-fatal-tandem-accident-in-b-c-1.1681084

Got off light. Negligent homicide.

[[email protected]]

Happened right down the valley from where I fly. We share the airfield with an unrelated hang glider winch launch operation so we talked a lot about the incident. Something similar happened with a hot air balloon ride operator a few years back. The balloon operator got a heavier sentence because he seemed to be systematically reckless. The hang glider pilot screwed up and made one big mistake. The sentence seems about right, maybe a bit lighter than I would have expected. I actually thought he might get a bit more time because it's said he swallowed a memory card after the accident which could be considered an attempt to conceal/destroy evidence.

[Soartech]

On Thursday, February 13, 2014 12:49:06 PM UTC-5, son_of_flubber wrote:
> http://www.ctvnews.ca/canada/hang-glider-pilot-sentenced-to-5-months-in-jail-over-fatal-tandem-accident-in-b-c-1.1681084

As fun and rewarding as hang gliding is it is missing one important thing that sailplane pilots use.
There is not a culture of using a written, rigid check list. Yet, like us, they assemble their craft before every flight.

[joesimmers[_2_]]

> As fun and rewarding as hang gliding is it is missing one important thing that sailplane pilots use.
>
> There is not a culture of using a written, rigid check list. Yet, like us, they assemble their craft before every flight.


Many sailplane pilots have never used a written checklist either, I for
one have NEVER used a WRITTEN checklist.

Most people I have seen struggle to assemble their gliders do use checklists, hmmm.....

I used to be a hangglider pilot also so I guess that's where I picked it up.

[son_of_flubber]

On Friday, February 14, 2014 1:03:15 PM UTC-5, Soartech wrote:

> There is not a culture (in hang gliding) of using a written, rigid check list. Yet, like us, they assemble their craft before every flight.

I see that the title that I chose for this topic reflects my hasty interpretation.

To put this in a more correct context, the pilot plead "guilty". He was not found guilty of not using a checklist. But I think that it would have boiled down to that if the case had been tried.

excerpt from article:
>Had Orders (the pilot) performed those safety checks, Godinez-Avila's family would have been spared the heartbreak they now endure, said B.C. Supreme Court Judge Brian Joyce.

"I do not accept the suggestion made ... that what occurred here was merely a momentary loss of attention," Joyce told the court.

"There is a clearly established procedure that is to be followed in conducting a tandem hang-gliding flight. ... Mr. Orders failed to do all of these things."<

So unlike the judge, I find it easy to accept that due to a "momentary loss of attention" the pilot simply forgot to check the passenger's attachment to the hang glider. Like every other human, my memory is faulty and I'm prone to distraction. The judge expected the pilot to follow the "clearly established procedure". So the judge expected the pilot to flawlessly remember and execute all of those steps. That is an unreasonable expectation and if the case had been tried, the point would have been clarified.

I speculate that it would have come out in trial, that knowing the unreliability of his memory, the pilot was negligent every time he flew without a written pre-flight checklist.

My take away is that some future prosecutor will argue that it is criminally negligent to NOT use a written preflight checklist. In the meantime, that judge in Canada expects pilots to have perfect memories, so we might as well use written checklists.

[joesimmers[_2_]]

Yes in the hanggliding world checklists are pretty
much non existent, you would get laughed at for having one, but what they do use is something called a "hang check"

What this is is before you launch off of a cliff or slope,
you have an assistant hold your nose wires and you drop
down into the prone position, when you do this you can crank your
head around and visibly see that you have connected your carbineer
correctly to your hang strap and backup hang strap. Usually your
assistant also verifies this but I always preferred seeing the
connection with my own eyes.

This was always common at any site I ever flew at.

I also owned a tandem hangglider and did 60-70 tandem flights
total, I would never consider launching tandem without doing
a proper hangcheck, and I have never been at a site where anyone
ever launched tandem without doing this, you could expect a bunch
of people to start screaming if they ever saw this.

I am not confident a checklist would have saved this tragedy, but I
am confident that a hangcheck would have avoided it.

By the way hanggliders are far more complicated to assemble
than a sailplane is.

[son_of_flubber]

On Friday, February 14, 2014 5:57:41 PM UTC-5, joesimmers wrote:
> Yes in the hanggliding world checklists are pretty
> much non existent, you would get laughed at for having one, but what they do use is something called a "hang check"

So do you go through an unwritten preflight checklist for anything that is not verified by the hang check?

[[email protected]]

On Friday, February 14, 2014 7:22:14 PM UTC-5, son_of_flubber wrote:
> On Friday, February 14, 2014 5:57:41 PM UTC-5, joesimmers wrote:
>
> > Yes in the hanggliding world checklists are pretty
>
> > much non existent, you would get laughed at for having one, but what they do use is something called a "hang check"
>
>
>
> So do you go through an unwritten preflight checklist for anything that is not verified by the hang check?

So typically we perform a preflight of the hang glider itself. This is a walk-around/touch-around of the glider after assembly or a hard landing to insure that it is assembled correctly, no bent tubes, wires straight and unkinked, double check bolts/nuts, etc. This is a pretty standard procedure and is documented in the glider manual.

I personally also perform a prelaunch check (just as I'm getting situated to launch) similar to the "SCRUB CATS" verbal check that some sailplane pilots use. I've modified it a bit for the hang glider but it works for me.

S= Straps; hooked in and check the suspension.
C=Canopy; helmet on and buckled.
R=Release; When towing, check the release system.
U=Undercarriage; rock upright in the harness to insure harness leg straps are proper.
B=Brakes; Check parachute pins.
C=Controls; insure clearance above the base tube.
A=Altimeter; check altimeter, vario, and other instruments to be on and properly set.
T=Trim; check the VG.
S=Slop; insure that nothing is dangling which could create problems with launch (especially with the tow cart.)

I also verbally state "Hooked in, Locked in, and Preflighted". This is where I will look and confirm that I am hooked into the hang strap, the carabineer is locked, and mentally recall the glider preflight process. I then verbally say "Attitude Check" where I make a final assessment of my physiology at the moment to insure I'm up to the task of committing aviation.

Not all hang glider pilots use a written or verbal check list but the preflight walk around is pretty standard.

The Canada incident is really sad and could have been prevented with a full and proper hang check.

Danny Brotto
LS-8/18 "P6"
Wills Wing U2 145
Wills Wing Falcon 170

[Roy Clark, \B6\]

Hazardous Thoughts - Attitudes & /Antidotes:

1. Anti-authority:
The rules are for others, not for me.
/Follow the rules. They are usually right.

2. Impulsivity:
Do something - anything, right now!
/Not so fast. Think first.

3. Invulnerability:
It won't happen to me.
/It could happen to me.

4. Macho:
Taking foolish chances shows you have the right stuff.
/Taking foolish chances is foolish.

5. Resignation:
I'm helpless; I can't do anything.
/I'm not helpless. I can make a difference.

-Tom Knauff, world recognized glider flight instructor
and FAA safety consultant

3 out 5 (Nos. 1, 3, and 4) Joe.

Please post where you fly. Some of us might not share your clearly Hazardous Thoughts & Attitudes.

[CJ[_3_]]

I have to agree with Roy on this one. What kind of culture laughs safety
conscious pilots applying worlds best practice off the airfield? The
worlds airlines don't use checklists just to keep their printers in
business.

I always have and always will use a checklist. Not a "do list" but a
checklist post assembly and another pre-launch, once pre-launch items have
been actioned by pneumonic, to confirm required actions have been
completed.

CJ

"Roy Clark, \"B6\"" > wrote:
> Hazardous Thoughts - Attitudes & /Antidotes:
>
> 1. Anti-authority:
> The rules are for others, not for me.
> /Follow the rules. They are usually right.
>
> 2. Impulsivity:
> Do something - anything, right now!
> /Not so fast. Think first.
>
> 3. Invulnerability:
> It won't happen to me.
> /It could happen to me.
>
> 4. Macho:
> Taking foolish chances shows you have the right stuff.
> /Taking foolish chances is foolish.
>
> 5. Resignation:
> I'm helpless; I can't do anything.
> /I'm not helpless. I can make a difference.
>
> -Tom Knauff, world recognized glider flight instructor
> and FAA safety consultant
>
> 3 out 5 (Nos. 1, 3, and 4) Joe.
>
> Please post where you fly. Some of us might not share your clearly
> Hazardous Thoughts & Attitudes.

[joesimmers[_2_]]

Just to be clear I do have checklists and procedures
that are always followed in a very thorough manner.

They are not "written" is what I am implying, I think this
is very common whether pilots admit it or not.

I have helped a lot of very experienced pilots assemble their gliders
over the last 15 years, the ones that had a "written" checklist in
their hands during assembly are less than 10%.

[son_of_flubber]

On Saturday, February 15, 2014 7:57:19 AM UTC-5, joesimmers wrote:

> I have helped a lot of very experienced pilots assemble their gliders
over the last 15 years, the ones that had a "written" checklist in
their hands during assembly are less than 10%.
<

I agree, glider pilots neglect fundamental and simple to implement safety practices.

There is a difference between "common practice" and "aviation industry best practice". The "aviation industry best practice" is a written checklist.

A commercial operator who does not follow "best practices" and who has a fatality is going to be accused of negligence. That the operator was following common practice is not a good excuse.

I know of a top human factors expert, a guy who spent his life studying pilot errors. He goes one step further than written checklists when assembling his glider. His checklists are in laminated plastic sheets and he uses a dry erase marker to check off the steps as they are completed. I gather from that that he knows of people who have made assembly mistakes even when using a written checklist.

[Evan Ludeman[_4_]]

On Saturday, February 15, 2014 10:03:26 AM UTC-5, son_of_flubber wrote:

> I know of a top human factors expert, a guy who spent his life studying pilot errors. He goes one step further than written checklists when assembling his glider. His checklists are in laminated plastic sheets and he uses a dry erase marker to check off the steps as they are completed. I gather from that that he knows of people who have made assembly mistakes even when using a written checklist.

I disagree with having a checklist in the hand during assembly. Way too many people confuse "assembly" with "preflight" and it sounds like this guy is confused. Oops, he's a "top human factors expert", does that make me anti-authority? FWIW, I have post-assembly, pre-flight and pre-take of checklists. I use them all and I recommend this sequence to anyone.

The internet FUD (that's "Fear, Uncertainty, Doubt") fight gets tiresome.

Evan Ludeman / T8

[Roy Clark, \B6\]

On Saturday, February 15, 2014 7:03:26 AM UTC-8, son_of_flubber wrote:
> I agree, glider pilots neglect fundamental and simple to implement safety practices.
>
>
> I know of a top human factors expert, a guy who spent his life studying pilot errors. He goes one step further than written checklists when assembling his glider. His checklists are in laminated plastic sheets and he uses a dry erase marker to check off the steps as they are completed. I gather from that that he knows of people who have made assembly mistakes even when using a written checklist.

Another Canadian opinion on Normal accidents: human error and medical equipment design.

Steven Dain Department of Anesthesiology and Perioperative Medicine, University of Western Ontario, London Health Sciences Center, London, Canada.
The Heart Surgery Forum (Impact Factor: 0.46). 02/2002; 5(3):254-7.
Source: PubMed

ABSTRACT High-risk systems, which are typical of our technologically complex era, include not just nuclear power plants but also hospitals, anesthesia systems, and the practice of medicine and perfusion. In high-risk systems, no matter how effective safety devices are, some types of accidents are inevitable because the system's complexity leads to multiple and unexpected interactions. It is important for healthcare providers to apply a risk assessment and management process to decisions involving new equipment and procedures or staffing matters in order to minimize the residual risks of latent errors, which are amenable to correction because of the large window of opportunity for their detection. This article provides an introduction to basic risk management and error theory principles and examines ways in which they can be applied to reduce and mitigate the inevitable human errors that accompany high-risk systems. The article also discusses "human factor engineering" (HFE), the process which is used to design equipment/ human interfaces in order to mitigate design errors. The HFE process involves interaction between designers and endusers to produce a series of continuous refinements that are incorporated into the final product. The article also examines common design problems encountered in the operating room that may predispose operators to commit errors resulting in harm to the patient. While recognizing that errors and accidents are unavoidable, organizations that function within a high-risk system must adopt a "safety culture" that anticipates problems and acts aggressively through an anonymous, "blameless" reporting mechanism to resolve them. We must continuously examine and improve the design of equipment and procedures, personnel, supplies and materials, and the environment in which we work to reduce error and minimize its effects. Healthcare providers must take a leading role in the day-to-day management of the "Perioperative System" and be a role model in promoting a culture of safety in their organizations.

http://www.researchgate.net/publication/10941806_Normal_accidents_human_error_and_medical_ equipment_design

A full .pdf copy is available for those who wish to become more informed about human error issues.

[Don Johnstone[_4_]]

This posting raises a very interesting question, nothing to do with
aviation but everything to do with what we do about a person who makes a
mistake, who knows what he should do, which he has every intention of
doing, which he has done many times before without error but which he fails
to do on one occasion resulting in tragedy.

What is to be gained by punishing him by putting him in prison? What useful
purpose does it serve?

Did it reduce the chance of him doing the same thing again? No of course it
did not, the result of his failure saw to that.
Did it encourage others to take more care? It might except in this case
there appears to be no intention of being careless, people do who make
mistakes in general have no intention of making mistakes, the opposite in
fact.
The only possible explanation for the sentence is revenge which achieves
nothing. What this sort of action does do is discourage people from
reporting honest mistakes. There are other factors that also disincetivise,
peer ridicule being one of the major ones.

The action by the court in BC has done absolutely nothing to prevent a
similar action in the future. If in this case, the error had been
discovered prior to the point at which the result was fatal, during the
takeoff run for instance, the chances are this would never have seen a
court at all.

The 5 months was solely the result of the outcome and served no useful
purpose at all. Punishment is appropriate perhaps for deliberate acts but
never ever for errors, however tragic.

During the two world wars many soldiers were shot for desertion, punished
for running away. We now know that many of these unfortunates were sick and
had no control over what they did, seems we never learn, sometimes I wonder
if we want to.
For me the real criminals in this case are the judge and prosecutors.

[[email protected]]

This is not a hangglider cultural or safety issue, this is a human pilot issue. Takeoff without elevator connected much? Written checklists are not a cure all. If you need USTALL written down, you are feeble minded. Funny to see the ADM anti-authority stuff trotted out, we need a dangerous attitude for kicking accidents out of our ingroup so we can pretend the cause doesn't apply to us.

[Tony V]

On 2/14/2014 5:57 PM, joesimmers wrote:
> Yes in the hanggliding world checklists are pretty
> much non existent, you would get laughed at for having one, but what they do use is something called a "hang check"
>
> What this is is before you launch off of a cliff or slope,
> you have an assistant hold your nose wires and you drop
> down into the prone position, when you do this you can crank your
> head around and visibly see that you have connected your carbineer
> correctly to your hang strap and backup hang strap. Usually your
> assistant also verifies this but I always preferred seeing the
> connection with my own eyes.


Yeah, me too. I personally knew 2 people that failed to do that on cliff
launches - they were not hooked in. One was fatal, the second pilot was
a gymnast who "simply" hung onto the base tube, swung up, trapeze like,
hooked in and landed safely.

Tony

[Bob Whelan[_3_]]

On 2/16/2014 8:46 AM, wrote:
> This is not a hangglider cultural or safety issue, this is a human pilot
> issue. Takeoff without elevator connected much? Written checklists are
> not a cure all. If you need USTALL written down, you are feeble minded.
> Funny to see the ADM anti-authority stuff trotted out, we need a dangerous
> attitude for kicking accidents out of our ingroup so we can pretend the
> cause doesn't apply to us.
>

I think Gregg has touched upon "the crucial point" insofar as reaching the
goal of "100% eliminating pilot assembly fatalities from improper/incomplete
rigging" is concerned...whether of hang gliders, sailplanes, ultralights or
whatever. (Of course, that goal's unattainable...more below.)

Sailplane guys have convinced me any sailplane driver can overlook even the
most basic of things. (I - once and so far ONLY once! - failed to safety the
only physically-detachable [main] pin in my auto-connecting,
"bozo-easy-to-rig" 15-meter glass glider. It would be difficult to devise a
simpler manual-safetying device than the one I actually rotated to the
safetied angle, but did not [obvious at a glance] verify HAD safetied. The
only thing that saved my life was falling out after several hours on a rotory
day in which I failed to wave-connect; discovered the gaff while de-rigging.
Yes, the main pin had moved forward about an inch or so. Yes it's the closest
I've knowingly come to a heart attack.)

Hang glider guys have convinced me the problem isn't confined to "idiot
sailplane drivers."

Power guys have convinced me "the problem" isn't limited to rigging issues.

The on-final-approach death of an IA known of through a sailplane-rated
sibling (friends with the deceased and his widow - all glider owners) - for
(possibly? apparently?) failing to properly engage/verify elevator control of
the factory-built, "LSA-like" glass bird he'd spent a week or so preparing,
then annualling prior to (attempting) delivery to its new/first owner,
"merely" provided further substantiation to a personal belief that has grown
within me since bumbling into soaring after school, in 1972.

It's simply this: somehow or other Joe Pilot has to convince himself that
certain activities not done, or poorly done, ARE likely to KILL JOE PILOT,
soon and permanently. Call it fear, call it faith in fallibility, call it
whatever you wish. But - I believe - until Joe Pilot truly internalizes this
sort of belief in some form or another, s/he hasn't done EVERYthing possible
to "self-inoculate."

I expect to hear/see cries of "panacea nonsense!" in response. Should they
appear, IMO they'll have as much validity applied to "checklist proponents"
(which includes me), and "technology fans" (and I'm one, when it comes to
auto-connecting controls, having benefited from owning an auto-connecter since
1981), etc. Point being, I've lived long enough as a pilot utterly enamored of
(in particular) everything associated with "sport aviation" (of every flavor),
to believe the - *I* certainly don't want to remove it - weak link in any
aircraft's control loop is Joe Pilot. Me.

I firmly believe that any thought along the lines possibly tending to diminish
the belief that I am a seriously flawed, weak-piloting link is dangerous TO
ME. EVERYthing matters to me as Joe Pilot, just some things more than others.
Those things that others have demonstrated to me can kill me are Right Up
There in seriousness. No imagination required.

I also won't be surprised to receive feedback along the lines of "Your
approach isn't guaranteed to (alternatively, will not) prevent 100% of all
pilot-error rigging fatalities." Indeed it will not. So what? Your point is?

To me, the goal is to minimize "as much as is possible" the sort of "obvious,"
"predictable," "preventable," "bozo-ish," sad, tragic deaths that do so much
to depress pilots in general, eviscerate joy from the affected families'
lives, provide ammunition for safety nazis and those who would rid the world
of any activity with which they disagree, etc., etc., etc.

Personally, I've never been able to imagine ANY sort of good flowing from
those sorts of deaths, save for the rationale that maybe - just maybe - some
of those still living might be motivated to become "somehow safer" pilots from
pondering what might be learned from others' foolishness, forgetfulness,
arrogance, haste, or what-have-you.

Prior to beginning piloting lessons, learning from others' mistakes had become
a part of my approach to life. That works for me. But I'm not you, so HERE is
the crucial, indisputable fact: Darwinism is real. One way or another, my
approach - and your approach, too - is a lifelong thing.

Call me a fan of checklists, a believer in "hazardous thoughts," someone who
tries to be careful and sensible and diligent and who tries to fly to the
"safe limits" of his ever-changing skills and currency. No need to call me
fallible; I do that myself. Regularly and - so I actively strive - always.

Bob W.

P.S. So far, the soaring "off season" in the U.S. seems to have been -
"Joyfully!" he happily sez - devoid of "stupid sailplane pilot tricks." I
sincerely hope all of us actively work diligently to keep that trend going!!!

[waremark]

Don argues against sending anyone to prison for the appalling outcome of a careless omission. In the UK, in the law relating to driving, we have offences of careless driving and of dangerous driving. Dangerous driving is much worse than careless driving. Until recently, after a fatal car accident, you used only to be sent to prison if you were guilty of dangerous driving. The tabloid newspapers used to screan when 'drivers who killed people' did not get sent to prison. Recently, the offence of causing death by careless driving was introduced with a maximum prison sentence of 5 years. It seems to make the tabloids happy. Personally, I agree with Don - we are all sometimes guilty of carelessness, we nearly always get away with it, I don't think you should be sent to prison if someone dies only because of the disastrous consequences of the same level of carelessness.



On Sunday, 16 February 2014 01:56:40 UTC, Don Johnstone wrote:
> This posting raises a very interesting question, nothing to do with
>
> aviation but everything to do with what we do about a person who makes a
>
> mistake, who knows what he should do, which he has every intention of
>
> doing, which he has done many times before without error but which he fails
>
> to do on one occasion resulting in tragedy.
>
>
>
> What is to be gained by punishing him by putting him in prison? What useful
>
> purpose does it serve?
>
>
>
> Did it reduce the chance of him doing the same thing again? No of course it
>
> did not, the result of his failure saw to that.
>
> Did it encourage others to take more care? It might except in this case
>
> there appears to be no intention of being careless, people do who make
>
> mistakes in general have no intention of making mistakes, the opposite in
>
> fact.
>
> The only possible explanation for the sentence is revenge which achieves
>
> nothing. What this sort of action does do is discourage people from
>
> reporting honest mistakes. There are other factors that also disincetivise,
>
> peer ridicule being one of the major ones.
>
>
>
> The action by the court in BC has done absolutely nothing to prevent a
>
> similar action in the future. If in this case, the error had been
>
> discovered prior to the point at which the result was fatal, during the
>
> takeoff run for instance, the chances are this would never have seen a
>
> court at all.
>
>
>
> The 5 months was solely the result of the outcome and served no useful
>
> purpose at all. Punishment is appropriate perhaps for deliberate acts but
>
> never ever for errors, however tragic.
>
>
>
> During the two world wars many soldiers were shot for desertion, punished
>
> for running away. We now know that many of these unfortunates were sick and
>
> had no control over what they did, seems we never learn, sometimes I wonder
>
> if we want to.
>
> For me the real criminals in this case are the judge and prosecutors.

[son_of_flubber]

On reflection, the thing that sticks with me about this incident is what came out at the trial as an explanation. The pilot was distracted by his new video camera.

I guess that whenever something new is introduced into the cockpit, we are more likely to forget some routine but essential preflight steps.

[Ramy[_2_]]

This is probably the most important lesson.
Skipping a checklist most likely wouldn't cause you to forget something. Distraction will. Even if you always use checklist, distraction will cause you to miss an item in your checklist. Distraction is your enemy.

Ramy