Removing the traps-or making them known.
One day I got the "phone call from hell".
It was ASA, and the voice said "one of your aeroplanes has had an engine failure at Woop Woop and has landed on the road. Do you want me to call the police, or will you do it?"
After I had stared at the wall for about a minute I phoned the refueller at Woop Woop and asked him to provide a vehicle, and go out and look after the pilot and passengers until I could get another aeroplane to pick them up. (refuellers know everything, and control the resources out there). Then I phoned the LAME who looked after that aeroplane.
Within five minutes I got a call from the Woop Woop refueller to say"they put AVTUR in that aeroplane". It had a piston engine and should have had AVGAS. The LAME was pleased to hear this news, but I was not.
So this is a simple case isn't it? The pilot stuffed up. So you sack him, and get on with the work. Problem solved. Isn't it? Or is it?
That's not what happened. When the pilot got back to base, I shook his hand, and thanked him for saving the aeroplane and passengers. I told him to take a week off work, and that his job was safe.
Then I talked to the Woop Woop refueller and found a couple of things I did not expect. The avtur drums and the avgas drums were stored in close proximity, in the the same compound. I remember the old drums used to have large areas of bright colour as well as small lettering to indicate what grade of fuel they contained. This company painted all of the drums the same colour, and the small identifying lettering was a different colour for each grade. One layer of the swiss cheese had been removed. But the one I did not expect in Australia was THE REFUELLERS COULD NOT READ!!!
The Woop Woop refueller agreed to make sure the different types of fuel were stored at different sites, and to be more carefull allocating labour. He was normally present himself, but was not on this occasion). He built more fences.
I talked to our ever helpful FOI and he promised to speak to the fuel company about more prominent labeling on fuel drums.
Sure, the pilot could have done it better. Couldn't we all? He had had a very valuable lesson (one you cannot buy) and did lot's of good work for me before going on to bigger and better things with my recommendation and support.
Let him who is without sin throw the first stone.
Had I just sacked the pilot, the trap would still be out there for others, and no-one would know. This would have been the simplistic, military style convenient pseudo solution that is too common in aviation. And it would have adversely affected one of the industry's better pilots.
A much better outlook was described in 1947, and is still being denied.