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Old 8th Oct 2021, 13:38
  #131 (permalink)  
DrSM
 
Join Date: Oct 2021
Location: Berkshire
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Jeopardy and Blame

Many of the contributors to this thread might be surprised to see a response from me, but I feel that if we are committed to making things better, and if any change for the better come is to from my bad example, then a degree of honesty and acceptance of criticism is warranted. I have not seen all the comments, but I can imagine what most of them say - and who they blame. For the avoidance of any doubt, may I set out here that I will never take umbrage or hold any personal grudge (nor will I ever seek or look to take action) against anyone who quite rightly questions and expressing shock and dismay at the apparent failings and errors highlighted in this most unfortunate - and ultimately avoidable - tale. Whatever is said and how ever it is said, I accept your right to say it.

I have seen a few comments that make reference to both the CAA and the Owner. May I state for the record, that the behaviour of both these has been exemplary and they have both set the highest standards of Just Culture and conduct. Neither of these people or organisations warrant or deserve the slightest criticism, and in fact they deserve your admiration and praise for their highest standards of conduct and empathy. I made two telephone calls within the first hour of landing. The first was to the Owner's office and the second was to the CAA to report what had happened. I will not share the details, but needlessly to say the Owner's office question was 'was this dangerous?', and my reply was that it was and it was my fault. The fact that they subsequently looked to understand the circumstances more fully rather than sacking me on the spot, is beyond belief and much to their credit - they are very rare people and deserve nothing less than your admiration. Similarly with the CAA, they accepted the information I gave them and rightly put me on notice that I may be subject to action following further investigation, but again - if you ever doubted that the CAA understands and follows Just Culture, I am an example that they do. The AAIB report paints a picture, but it is a picture of the incident - and you should all trust that the CAA make their own judgements. I was always fully ready to accept the judgement, whatever it was going to be.

I wish to also make sure everyone, who might not have a true understanding of the pressures and threats that are fundamentally part of Corporate Aviation (and you will never eliminate them, they can only be managed - it is like asking a fish not to swim in water); there was absolutely zero pressure applied by the owners in this story. Any pressure that might have been there (and there will always be pressure in any commercial aviation), it was not from them.

The reality is that no matter what your experience, and no matter how many excellent jobs or flights you have done in your past, we must all accept (or we should accept) that on any given day you will be in jeopardy of making errors in judgement and skill for as long as you sit in a cockpit. You may hope and pray that your worst day does not end up under the microscope of the AAIB, but it may - and you should never relax from watching out for the traps and pitfalls that can build quietly and silently into your otherwise 'normal day'. You all have a right to be brutally critical of my errors and mistakes, but I caution you to be careful - to fully understand any environment (and corporate aviation to off airfield landing sites at night are a very particular environment) there are many things you need to experience first hand to fully understand. It is very easy to say 'I would never' or 'that would never be me' - and I sincerely hope that it will never be you, if for no other reason than you have read this AAIB report - but there are a few things that I will tell you now: In an incident that rapidly develops into a life threatening situation, for the pilot flying (with all the other normal demands on attention in the cockpit) it cascades from normal to emergency like falling off a cliff, and the demands on your attention jump from 10 per second to a 1000 per second and if you think you will be reliably 100% of the professional pilot you are in the simulator - you are deluded. My experience, and you can disagree again, is that you will be lucky to hang onto 20% of that normally competent and good pilot - and you just hope that the remaining 20% is the skill and experience that climbs you out of the hole alive. I am not talking about the normal emergency situation, I am talking about the type of emergency situation where you know that what you do in the next 3 seconds determines the fate of you and everybody on board - and if you question whether that conscious thought actually takes place, remarkably enough, the answer is yes.

Should I have resigned? If anyone in this forum doesn't think that was my first, second and third thought - you do me an injustice. I ask you to understand that in my role I had to think about what that would have meant for the jobs and security of all the extremely valuable, professional and superb people that work in our team. I owed them my heartfelt apologies for letting them down so badly, but I also owed them every ounce of my energy and effort to make sure their jobs would be ok after it.

We have discussed this very openly and completely transparently in the team - when it first happened and when the report was published. I have no issues talking about it with anyone who genuinely wants to learn something about avoiding this again.

The microscopic examination and judgement of an AAIB investigation is never a kind or friendly experience, but it is a necessary and useful thing. You should note that there are possibly a thousand things you do in a day that are 'normal' variations on your best performance, and they will never be judged until the day there is a bad outcome; but once there is a bad outcome, everyone of them will be examined as an ;'error' or 'failing' that could or would contribute to the bad outcome - whether it did or didn't (because nobody can reliably know for sure).

I do not expect anyone to agree with whether I should still have a job, or whether I should still have a licence, but I ask you to listen to me when I advise you to never relax your attention to the subtle changes in threats in your normal day, that will build up without making a big noise or having one critical moment. I also advise you to recognise that no matter how good a pilot your are, as long as you sit in a cockpit, you are in jeopardy of making bad calls and bad judgements. Finally, my recommendation is that you listen to any first question of doubt in your mind during pre-flight planning, pause and check the cause for doubt - once your are airborne, the corridor of options can collapse around you and leave you just one door of consequence at the end remarkably quickly and possibly quicker than you can react.

I would ask you to all respect that this is not my finest moment, and my career will forever be coloured by this day in my life, but it is right and proper you should learn from it - as that is what we all owe to the future generation of pilots, learn from other's mistakes.

I understand your anger, but do not for a minute think that this matches my shame. But as an industry, hopefully, we will be better.

I do not propose to respond to any other posts on this thread - but you will have no objections from me regardless of what you feel the need to say.
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