Guest Post: Fear, Blame Cause 92 Innocent Deaths

Today’s post is from James Lawther. He writes about process improvement at

On the December 1st 1974 a TWA flight was coming in to land at Dulles Airport, Washington DC.

As it approached the runway the air traffic controller uttered the words “cleared for approach”.  Shortly afterwards the plane crashed into the side of Mount Weather.  All 92 passengers and crew died.

In the investigation that followed it became clear that the accident was caused by a simple miscommunication. When the Air Traffic Controller said “cleared for approach” he meant “the runway is empty”, the crew of the plane however heard “continue on this trajectory” and ploughed straight into the side of a mountain.

A terrible mistake that should never have happened

I have no doubt that you know all about the accident pyramid.  If you work in the safety industry you incorporate it into your every waking moment.

To create a safe working environment focus on removing the near misses, stop them from happening:

  • Lots of near misses lead to a few minor accidents
  • Lots of minor accidents lead to a few serious accidents
  • Lots of serious accidents lead to a fatality

If you work in the safety industry you know that near misses kill.

So the way to prevent fatal accidents is simple, every time you have a near miss, report it, act on it, and remove its cause and the chances of having a death drop.

The logic holds true, regardless of whether you work in a call centre, a supermarket, a nuclear power plant or the airline industry.

This is not new news

The safety pyramid was developed by H. W. Heinrich in 1931.  The idea was widely accepted by the 1970’s and the Federal Aviation Authority (who were responsible for policing the skies) had made it a legal obligation that pilots report near misses.  Not doing so was a federal offence.

But despite the law near misses were going unreported.

This was far from the first time that a plane had had a close encounter with Mount Weather.  Only 6 weeks earlier a United Airlines flight screamed meters above the tree tops, terrifying the birds when its pilots had made exactly the same mistake.  But not one of the crew of the United Airlines flight said a word.

What were they thinking?

If they had reported the incident the passengers and crew of TWA flight 514 may very well still be alive.  They all knew how close to death they had come, yet they kept their mouths firmly shut.

Why? Because they were scared.

If they had reported the near miss to the FAA they would have immediately been investigated for misconduct.  The pilots could have lost their hard won, highly paid jobs in an instant if they were suspected of being at fault by the FAA.  So the pilots had a choice:

  • Either report the incident and take their chances with the unemployment queue
  • Or keep their mouths shut and chalk it up to experience.

What would you do?

So the only way to overcome the problem was to remove the fear.

It must have been hard for them, but in the end the FAA realised that they were the problem, so they subcontracted out accident reporting to NASA.

NASA set up the Aviation Safety Reporting System (ASRS).  They collate and investigate all the near miss data, detail the causes and pass the data onto the FAA who then use it in accident reduction programmes.  But first they strip out the names of everybody involved so the data is totally anonymous.

Sensing that pilots may still be reluctant to report incidents the FAA went a step further.  If you are a pilot who has come under suspicion of misconduct by the FAA and you can show that you reported the incident to ASRS then, in the eyes of the FAA, it shows you have a “constructive safety attitude”, which is as close as the FAA get to giving anybody a Get out of Jail Free Card.

It is all about human nature

NASA have no power to prosecute anybody, nobody is scared of reporting a near miss, nobody gets blamed.  And they issue get out of jail cards.

If you go to the ASRS web site they have a catchy little strap line that says it all:

Confidential Voluntary Non-Punitive

People will always act in their own interests first.  So if you really want to improve safety remove fear and blame from those who get things wrong.


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