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

On Thursday, February 13, 2014 12:49:06 PM UTC-5, son_of_flubber wrote:
http://www.ctvnews.ca/canada/hang-gl...-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.

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.

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.

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.

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%.

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.

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

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/publicat...uipment_design

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

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.

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.