Boring Old Risk Management
The two pictures show the same event but with very different communication methods. Effective communication tells a story...
Looking back, it’s hard to see how flying through mountainous terrain at 250 feet became so mundane.
But that's the way it was. We flew regularly and we considered ourselves as experienced. The weather brief had showed a reducing cloud base on our route and as always, some low-level turbulence. We had planned and flown this sort of route before and felt that we knew the risks.
We flew low through the Scottish valleys – stay low and remain visual was our plan. It was always the plan. When we hit the turbulence, we were low. Then very quickly the wing dropped, and we got lower. When I say hit, it felt and sounded like a hammer blow to the aircraft. It got worse and although I couldn’t see the flight instruments I wasn’t scared so much as excited, until I saw the co-pilot's face. He had his hands and feet on the controls, but the aircraft was doing something very different and very dangerous. Despite using full control inputs, the aircraft was banking very quickly to almost 90 degrees and descending. I don’t know if I closed my eyes or if I swore; both were feasible. I think I just froze.
We cleared the ridge. The valley opened up and the ground fell away below us. The subsequent silence on the intercom was broken by one of the crew in the aircraft hold. One of the crew had unstrapped as we hit the turbulence and was badly injured. “How bad?” We asked from the flight deck. “Bad. We need to get him on the ground – quickly”. The guys described his injuries. It was serious, head and back injuries and a badly broken leg. I could hardly speak when I tried to describe his condition to Air Traffic Control. I was angry and disappointed in myself – why couldn’t I do something so simple?
Everyone was shaken, so we did what seemed the natural thing. We carried on flying the route to a remote military airfield, just as we had planned. None of us had the capacity to re-think our route. It just felt better that we were doing something we could control. Thankfully the calm head of the Air Traffic Controller suggested that diverting the aircraft to a civilian airport with a nearby hospital might be a better plan than continuing in the other direction. We did just that and got our injured colleague into a hospital within 30 minutes. He survived his injuries and was home within a couple of months.
Did we effectively risk manage the situation? We had done what was standard operating procedure and stayed within the rules. We had briefed, but was that brief relevant and interactive? We followed procedures designed to protect us, but did we really assess the dynamic risks? We had simply towed the line. But sometimes doggedly following process can make us vulnerable, particularly if you’re not monitoring and constantly assessing new and potential risks. It’s not just a case of battling complacency. To understand our threat environment, we need to understand ourselves. It’s knowledge, skills and attitudes that need quality training, not just process.
As the last year has demonstrated, the world can throw us complex, novel and high impact situations, but we can often overlook the day to day risks, and we do that at our peril.
Anthony, NobleProg Risk Management Trainer / Consultant
At NobleProg we have trainers / consultants who have real world experience of the importance of having effective risk management tools and techniques. Sharing their experiences they can help you assess the risk management issues within your organisation.
The ability of any risk management system to adapt is key when dealing with dynamic and complex risks.