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“IzGudEnuf-itis” Can Be a Fatal Disease

I’ve always been amazed and impressed at the final reports of the National Transportation Safety Board on accidents and incidents that happen in our transportation system.  I have commented in this blog before on the value of the Root Cause Analysis process (check out the October 2012 blog on “Pre-Disasters and Halloween Ghosts of Mistakes Past”) and I have stressed the value of this process to truly understand all the obvious and hidden causes contributing to errors in complex systems.  The NTSB is the poster child for the RCA process.  They will drill down into an event going back decades if that is what it takes to understand all of the intertwined events that make up the root causes contributory to an incident.

I had my own NTSB moment this weekend and what I learned was sobering to say the least.  I landed my plane Saturday afternoon after coming back from the west coast of Florida.  The day was great, the weather clear and the flight was good except for lots of commercial traffic, as usual, in the air around Miami.  I always do a pre- and post-flight inspection of my airplane and when I landed back home and walked around it I was really wingshocked to find a huge dent and hole in the vertical stabilizer behind the right wing.  Thinking back on the flight I recalled that as I was putting the landing gear up after departing from Marco Island I heard a little “clunk” sound.  It wasn’t anything very loud and there were no changes in the flying characteristics of the plane or the aerodynamics and no changes with the instrumentation.  It was just a sound I hadn’t heard before but since everything checked out fine I really didn’t think much of it – until I walked around and saw the outside of the plane and the hole in the vertical stabilizer.

I couldn’t figure out what the heck I had hit that could have done so much damage.  It certainly wasn’t a bird strike – I’ve had one of those before and there is always a lot of blood and feathers around the dent.  Mine certainly wasn’t like the “miracle on the Hudson” where the engines shut down, fortunately that never happened to me.  It had to have been a piece of metal but what could have been 300 feet up in the air swirling in the wind over the Gulf of Mexico?  It became obvious to me that it had to come from the airplane itself so I checked the props – no damage or separated parts and the entire right side of the airplane was fine.  Then I remembered my post-flight inspection after I flew the plane the last time and the whole NTSB thing came to me in a very unpleasant rush.

The previous time I flew the plane I noticed that the right main landing gear needed some air.  I had struggled a little to remove the main gear wheel hub cover since one of the screws was stripped and the guy with the fuel truck who was helping me finally got the hub cover off with a big screw driver.  We filled the main gear and we put the hub cover back on – but the last of the three screws wasn’t fitting in perfectly.  “But” said I to myself in a rushed and stupid rationalization, “IzGudEnuf” (translation – it’s good enough).  Wrong – luckily not dead wrong – but very wrong indeed!  So, the next thing I looked for was the right main landing gear hub cover – and it was missing.

Working backwards with the NTSB RCA thing I quickly figured out that the problem was that the hub cover was slightly displaced from the wheel itself – “good enough” thought I, but not perfect.  So when I took off and accelerated to climb out speed the wheel must have been, by dumb luck, aligned just right with the stripped screw into the wind which allowed the air stream to flow between the wheel and the hub and peeled the hub back from the screw hole and ripped it off.  That was what struck the vertical stabilizer.  This was totally my own fault.  When I checked the gear hub and saw that one small area was not flush, it had even crossed my mind (briefly) that it just might separate but, “naw” I said to myself, that could never happen – right?  I just didn’t pay attention to that little voice in the back of my head that was trying to be heard and was giving me a warning.  “IzGudEnuf-itis” struck me down.

It’s going to cost me some bucks, and although it was a very close call no harm came of this – a near miss in our High Reliability Mindset speak.  There is no doubt in my mind that if I had been flying a jet the hub cover would have been sucked into the air intake of the right engine and caused a potentially catastrophic flame out during the most dangerous phase of flight – just after takeoff.  Then the NTSB would be writing this RCA not me and the final root cause of the accident would have been, “the accident was caused by a faulty decision on the part of the pilot in command to operate the airplane with a loose main landing gear hub cover that separated in flight and was ingested into the engine causing an explosion and crash of the aircraft with no survivors”.

So the lessons learned (again) for me from my own RCA are simple:

  • Good enough just isn’t
  • When it’s a big deal there’s no such thing as a small decision – even the smallest decisions have potentially huge consequences
  • You can rationalize any decision – don’t do it and delude yourself into believing your own rationalizations – they’re only there to trap you
  • Follow your own advice – play every decision out all the way to the worst possible outcome, then plan for it
  • The hardest voice to hear is that little voice in the back of your head warning you “don’t go there” – ignore him (or her) at your own peril  (I even wrote about this in a previous blog post and still didn’t learn this lesson!)
  • If it can happen it will – count on it
  • Use the RCA process, I mean REALLY use it, to understand all the little steps that lead to the incident and be sure not to repeat the mistakes
  • Learn from your own, and others’ near misses since you are not likely to get a second chance

This applies to everyday life just as much as it applies to every surgical procedure and every flight.  As much as write about and advocate for use of the High Reliability Mindset safety skills, I still fail sometimes.  This was a very real example of what the dire consequences of not following my own advice could lead to.  These types of events are our reality, every day, every time, and every patient.  Just one failure reminds me that I can only practice my HRMS skills and I will never graduate from the High Reliability Mindset School of Safety.  But I keep taking the classes.

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