A gem from the National Transportation Safety Board

I read accident reports from all sorts of sources. A few years ago I read through the entire NTSB online library for fun and I still keep up with the new ones. There were many good insights in the reports and I took quite a few notes. This is one of my favorites:

The report also cited industry data showing that pilots who intentionally deviated from standard operating procedures were three times more likely to commit other types of errors, mismanage errors, and find themselves in undesired situations compared with pilots who did not intentionally deviate from procedures.

This quote about pilots applies to any skilled trade, including ammonia refrigeration operators.

Source: National Transportation Safety Board, Attempted Takeoff From Wrong Runway, Comair Flight 5191, Bombardier CL-600-2B19, N431CA, Lexington, Kentucky, August 27, 2006, Aircraft Accident Report NTSB/AAR-07/05 (Washington, DC: NTSB, 2007).

About Brian Chapin

PSM / RMP Compliance Consultant
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2 Responses to A gem from the National Transportation Safety Board

  1. Reminds me of a video I just watched today where a guy was demonstrating a suppressor he had designed and manufactured for his semi-auto UZI (made legally on a Form 1 registration.) He shoots a few rounds without the “can” installed for comparison then engages the safety and screws the suppressor on.

    That is simply made of FAIL and the number of people defending him because “he put the safety on” was astounding.

    While a semi-auto UZI is likely one of the “safer” weapons to do this with for a number of reasons (it is not an open bolt gun like the auto version, it has a grip safety in addition to the manual safety) why would one take the chance? Sure, you might get away with it the rest of your life. But what happens if the “perfect storm” of errors ensues and you put a bullet through your hand or, even worse, an innocent bystander because you’re too lazy and/or stupid to take 10 seconds to clear the weapon completely? That’s when that sort of person lashes out in every direction because they’ve done it that way “a million times” and never had a problem…so it is a mechanical/design failure, etc. and not their fault.

    The moral of the story? Just because you get away with doing the WRONG thing a million times doesn’t make it right. Knowingly doing it the wrong way enforces bad habits and creates an atmosphere where “cutting corners” is the norm…and safety is the first casualty in such situations and rarely the last. In the end, the satisfaction of getting away with it a million times pales in comparison to the anguish of the “million and oneth” time when you don’t.

    In addition, one of the apologists linked a video of a VERY well known individual who does firearms training where he did the same thing with an M4 rifle and asked if we were challenging his “wisdom.” Well, his “fame” certainly doesn’t make him and those around him bulletproof and if he happened to attend our shoot coming up at the end of the month he would get the same one warning followed by ejection that Joe Schmo would get. We’ve gone 15+ years with nothing more than a handful of minor cuts and burns…not bad with what is likely over a million rounds downrange out of almost every automatic small arm you could think of including machineguns in the 100 year old and over range…from full auto .380ACP handguns up to 20mm anti-tank rifles.

    Various stoppages (every gun fails, every gun has a different procedure when it does), misfires (round does not ignite when fired, always a potential that it will spontaneously ignite), several “out of battery” discharges (VERY dangerous for those who don’t know as the round is not contained and can turn the firearm into a bomb), etc. All are mitigated through scrupulous handling and operation including constant observation by Range Officers and other knowledgeable persons present and a rule that ANYBODY who feels there is a potentially hazardous situation can call a ceasefire. We’d rather lose a few minutes of shooting for a misunderstanding than the rest of the day for a crisis!

    Sorry about the somewhat lengthy off-topic rant! Dealing with this a few hours ago STILL has me annoyed.

    In addition to any direct costs and/or injuries that such laxity can incur, the indirect costs from negative press can be even more damaging. Industry and the firearms community both can ill afford inviting bad press due to complacency and ignorance.

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