Flight Safety: Breaking the Chain of Events

Shawn Arena

Throughout my years in aviation, I’ve encountered a variety of situations in which by making the right decision, I avoided potential and real danger. And in the name of flight safety, I’d like to share another one of those stores here. This is a story that involves a chain of events that literally caused the hair on my arms tingle with trepidation, for I was witnessing in real life what Human Factors experts have called the “Swiss Cheese Effect.”

Dr. James Reason’s “Swiss Cheese” Model

For those readers who may not be familiar with Dr. James Reason’s “Swiss Cheese Model”, here is a brief primer. Dr. James T. Reason, from the University of Manchester, is considered the preeminent pioneer in the study of risk management and safety culture. In the mid-1990’s Dr. Reason published a document highlighting what he referred to as the “Swiss Cheese Model.” See the following graphic:

As one can see, there are several segments that represent layers or ‘links in a chain” of events that if aligned just right, can cause an incident or accident (i.e. the “Swiss Cheese Effect”). If however, the sequence of events is recognized, it re-aligns or breaks the chain and an accident is avoided. This is the background of this flight experience.

The Chain of Events in Real Life

In early 2002, I was managing a general aviation airport, owned by the City of Phoenix, AZ, named Phoenix-Goodyear Airport (GYR). During that time, local airport managers held a quarterly airport manager’s meeting at a selected Arizona airport to share day-to-day airport administration and issues of the time, so as to learn from each other. On the day of the meeting, I decided to rent a Cessna 172 from Glendale Municipal Airport (GEU), about 15 minutes driving time from my airport in Goodyear. Mark, Glendale’s airport manager at the time, agreed to come along rather than make the 122 mile, 2 hour drive to Show Low Regional Airport (SOW) where the meeting was being held. By flying, we could make the meeting at SOW, in northeast AZ, in less than an hour.

This is when the ‘chain of events’ and potential flight safety risks began. Event #1: The aircraft I had reserved was inadvertently rented out to someone else, so I had to take another that I had not flown before. “No big deal,” I thought to myself, I’d flown several 172’s from this flight school before with no problem. As I was conducting the interior preflight inspection, I noted that the engine would not start after a few efforts. “Oh, well,” I thought. Maybe it was just cold and hadn’t flown in a while.

Event #2: After I finally got the engine running to my satisfaction, I noted that the Number 1 COMM radio reception was very intermittent, but I continued to the run-up area to conduct the pre-takeoff checklist. As I started to listen to the Automatic Terminal Information System (ATIS) broadcast at GEU (i.e. a pre-recorded message telling pilots cloud heights, visibility, active runway and time), I recalled the weather report for SOW (Event #3) was a 30 knot crosswind upon landing, with gusts up to 45 knots. And this was at a 2200 foot runway located in mountainous terrain. Immediately after hearing the local ATIS, the radio knob literally broke off and fell to the floor.

Fortunately for me, it only took these three events to stop the chain. I radioed GEU ground control for taxi back to the ramp. I felt that not only had the “Swiss cheese holes” begin to align, but a slight but very apparent case of “get-there-itis” also began to creep in. Mark was, to say the least, very unhappy that we had to scrub the flight. I apologized but told him: “ I don’t care, I’d rather be in a position on the ground wishing we were airborne, versus being airborne and wishing we were on the ground.”

Yes, at first I was bummed too, BUT a strong dose of reality came across me saying enough is enough. I called Dennis, the Airport Manager at SOW, apologized for not making the meeting and we would catch up at the next meeting.

Flight Safety Lessons Learned

By no means am I postulating that no one would have continued a similar flight, but what I want to convey to my fellow airmen is that I reached my personal limits and was not willing to risk further events. As the saying goes: “Learn to fly another day.” The gravity of the chain of events really sunk in when I called Dennis the next day, and learned the winds actually increased about the time we would have arrived. Thank goodness I had chosen to remain on terra firma. Here is hoping others will pay similar attention to flight safety and avoid the “Swiss Cheese” from aligning for them!

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^{Featured Image by Marshall Segal}