A small plane crashed on the A58 near Roosendaal (NL) on Wednesday. The pilot was killed. Many more have gone wrong recently. How safe is small aviation?
“That there have been so many incidents recently worries us,” says Rademaker [representing the AOPA]. “Although I am not saying that small aviation is unsafe…” There are also concerns among the Infrastructure and Transport Ministry’s Environment and Transport Inspectorate (IL&T). This is partly reflected in the “Status of the [Dutch] Aviation 2023” report published in April 2024. The number of serious incidents and accidents in small aviation “is not structurally declining”. Fatal accidents also occurred in 2023.
The sub-headline and a quote from an article by Johannes Visscher published on 3 August in the ‘Reformatorisch Dagblad’. The article goes on to describe one of the conclusions from an OvV investigation: ‘Main causes of accidents in small aviation are “lack of flying skills” and inability to assess risks…’
Admittedly, things have not become any easier in the airspace over the Netherlands in recent years. And aircraft have also evolved enormously; most new GA aircraft contain equipment that a ‘big’ aircraft manufacturer would not be ashamed of.
You then also practise your hobby among lots of different actors in the same system. The system in which the GA pilot finds himself is far from simple: it is complex. And the annoying thing about complex systems is that they cannot be predicted. Actions in a complex system are affected by numerous different factors, while the actions themselves affect those factors in turn. Interactions have ‘emerging effects’, i.e. the effects of actions occur totally unexpectedly and in totally unexpected places. A bit simplified, this explanation, but hopefully the point gets across.
Of course everyone should prepare properly before a flight. And of course everyone should keep to the arrangements. Laws and regulations, procedures, in short, everything you know and could know about the trip you are about to make you need to know. And the skills you have mastered you should also know how to apply. A hobby that requires a lot and that is precisely why many people love it.
But the fact that you pursue your hobby in a complex system and that effects of actions in a complex system cannot be predicted is not really encouraging. Especially not when you have just learned all kinds of procedures (‘if this happens, you do this and that’ etc etc). Yet those procedures do matter!!!; at least they give a proven handhold, at least they ensure that the reactions to a situation or disturbance are as standard as possible. And they give the greatest chance of a satisfactory outcome, an effective effect. Also not unimportant, knowledge and training of how to apply procedures ensures that you can respond relatively adequately ‘without thinking’ initially when appropriate. It saves a huge amount of ‘expensive brain capacity’, capacity that you may desperately need during the remainder of the situation. So yes, know them, practise them, apply them and keep looking for more and better procedures and information. But there is no guarantee that the procedure will always have the desired effect, or crazier still, that a procedure exists at all for the situation encountered.
I digress a little here because I was interviewed by Johannes for the article in the Reformatorisch Dagblad (RD). I agreed to a short interview because I was not asked what had happened, or who had done what wrong (because I cannot and will not comment on that), but only if I wanted to answer some questions about my ideas regarding safety. During the interview, I may have made some controversial statements. Don’t get me wrong, I don’t find them controversial, but some readers of the RD apparently do. I was even called by a flight instructor (we have known each other for a while) who told me that I “really don’t quite get it after all”. Well.
I am not a GA pilot. I am a pilot though, military and commercial, low-level and fast, less fast and medium and large; now retired. I also started specialising in safety, especially ‘New’ safety (see also the October 2018 All Clear) and Human Behaviour. I am still active in these areas as a trainer, auditor and consultant. What I find very important, besides constantly gaining and updating knowledge and skills, is a sense of responsibility, self-knowledge and self-reflection, resilience , openness and mutual trust. It was in this light that I responded to the questions during the interview.
To start with resilience, make sure you know as much as you can about your hobby. Know the procedures, know the rules. Gather all possibly relevant information about a flight to be performed and study that information carefully. So yes, definitely those procedures too!!! Do scenario thinking: what can/should I do if this or that is not right; what if I get an engine problem there; what if that parachute area does turn out to be active after all; what if the weather turns out to be worse than predicted? Eat and drink enough, take something for the road if necessary. Go to the toilet beforehand.
But don’t just toil learning legislation and protocols. Procedures are not sacred, not a guarantee, remember? So use common sense too. If you must deviate from a procedure to avoid an unsafe situation, do so. I gave a banal example in the interview: it is forbidden to drive your car on the pavement, but if, to avoid a pedestrian or cyclist, you have no choice but to do so. Not blind, do keep thinking, but then just make that violation.
Self-knowledge and self-reflection are also very important to me; make sure you are physically and mentally healthy enough to perform the flight (I AM SAFE *). And look at yourself honestly in the mirror. “Am I really ready for such a complicated flight or manoeuvre yet?” Don’t cheat yourself, be honest and realistic about your performance and your limitations in that moment. This is also a piece of responsibility. Apart from the fact that you can seriously injure yourself and seriously damage the aircraft, you can also affect other people with the incident; just experiencing, seeing a serious incident can damage people even resulting in PTSD. Know your responsibilities and take them seriously. When in doubt, don’t do it!
If you need to act completely outside procedures, rules or legislation, or have done something very unwise, it is extremely important that you can share this safely. Perhaps you remember it, The Just Culture, one of the big five of Safety culture. If you’ve decided not to fly because the weather requires too much of your skills and you get laughed at ‘at the bar’ when you tell them, you’ll never tell them again and you’ll probably fly next time when it’s actually not wise. And the same goes for deviating from procedures. If you are immediately ‘shot down’ for not following procedure, why you did so can never be heard and no one can learn from it. Indeed, perhaps the procedure can be improved as a result of ‘your incident’ and the way you acted. But if you get shot at, or laughed at, or punished then you’d rather not tell next time; past experiences….
The latter also definitely touches on openness and trust. Something that is very important to feel safe in an environment. If you don’t have that trust, you don’t share things easily and openness suffers. Then the organisation cannot learn from your experiences and solutions either.
I am also an advocate of talking about things that went well; reflecting on why that landing was uneventful, or whether that difficult approach to that field went entirely according to plan and correctly. Sure, you can learn from mistakes, but a lot more goes right than goes wrong, so when things go wrong there are therefore few learning moments left. Therefore, start looking at the things that went normally and well and ask yourself why that is. Then when you do the same ‘at the bar’ with your colleagues you can learn from each other’s experiences. If you trust each other, if the culture is open and ‘just’, then you can even have mutual criticism about decisions taken or actions carried out, even if everything went ‘well’. In my opinion, those discussions are worth their weight in gold!
In the RD article, of course, there was not that much space to elaborate on any of this, it is written in a few short lines. “Procedures are not sacred” is might be read out of context, which appeared to be the case given some of the reactions.
Safe is not just a parachute or a crash helmet or safety glasses. Safe is also having a good environment where you can share information with each other and for each other without it being used against you. Safe is also using your common sense; safe is also looking at yourself properly in the mirror and daring to hold yourself accountable; safe is knowing and taking responsibility.
I wish everyone such a safe environment, and if we all put our backs into it, maybe soon it will become safer.
* I AM SAFE: Illness (illness), Alcohol, Medication, Stress, Alimentation (‘provisions’ – eating and drinking), Fatigue, Emotion