Being my own harshest critic is something that has been painful at times but still very insightful for me in both the operating room and the in cockpit and has helped me understand my own error tendencies. With some of these insights in mind, I realized that I’ve occasionally used an expression that has always ended with a bad outcome, “IzGudEnuf.” It translates to, “It’s good enough.” The problem being that it never is. Last month I said I would fess up about just such a mistake I made that led to some costly damage to my airplane. So here we go.
I was headed up to Ashville, NC, to drop my kids off at summer camp, but as I went through the pre-flight on my Turbo Saratoga I noticed that the right main gear needed some air. The mains have a wheel well door that retracts with the gear under the wings and it turns out that they hide most of the hub cover. The hub covers have to be removed to access the valve stems and the whole thing can be a frustrating little process as you have to rotate the tire to get all the screws out from behind the wheel well door and repeat the process to put the hub cover back on. This simple chore seemed to be taking forever since I also had to wait for the line guys to drive over with the air compressor. I was getting antsy to be on the way to beat some typical summer weather that was predicted to pop up over central Georgia. When it came to screwing the hubcap cover back on after putting the air in the main gear, I had to either get the tow bar back out and pull the plane a little—and it weighs about 4,000 lbs with full tanks—or do some contortions with the screwdriver to tighten the two screws that are partly blocked by the wheel well door. You know the rest of the story; rather than take the time and effort to pull the plane forward, rotate the tires, and have full access to the upper half of the hubcap cover, I screwed the upper half at an angle, didn’t get a good fit of the screwdriver to the hub screws, and didn’t tighten them properly. “IzGudEnuf,” I muttered to myself as I climbed into the airplane, called the tower, and rolled to the hold short line. I was about to be proven wrong.
As I retracted the gear climbing out over South Florida I heard a pretty distinct clunk; certainly not the normal sounds of an uneventful climb up to cruise altitude. I checked everything in the cockpit, the instrument panel and what I could see over the wings, and nothing was amiss. Control of the plane was totally normal so I thought maybe I had popped another one of the Everglades birds that fill the sky down here. The approach and landing in Ashville was uneventful and I had long forgotten the clunk I heard hours ago at the start of the flight. I got the kids set in their camp and went back to pre-flight the plane again for the ride home when I noticed a big dent in the right horizontal stabilizer. There were no feathers or blood so I knew it couldn’t have been a bird strike, and as I looked further, I noticed that the right main gear hub cover was missing. It didn’t take long to figure out what that bang was. The screws weren’t secure in the hub cover and it blew off, hit the stabilizer, and made a costly dent for me to fix. Once again, “IzGudEnuf” just wasn’t. This was about the only time I was glad not to be flying a really cool jet with two turbines on the tail because the hub cover would likely have been sucked into one of them and brought the plane down with the kids and me.
Lesson learned once again and again the hard way. I admit it, I had made the same mistake I talked about last month, looking without really seeing. I looked at the half-tightened screws in the hub cover but never got the entire picture of that into my brain or thought through the potential consequences of my sloppiness. I had violated my own safety standards and compromised a simple task of putting some air in the main gear, and then I made it still worse by accepting my sloppy job. I would never in a million years do this to a patient in the operating room but I had done it to myself and there’s no excuse. Adding insult to injury, I had to resurface the whole right horizontal stabilizer surface to atone for my mistake. I also invested in new hub covers that have a little trap door over the valve stem so you don’t have to take the whole hub cover off or rotate the gear from under the well door each time you need some air in the tires. At least it won’t happen again.
It didn’t take a profound epiphany to understand how I made this mistake; it just took a really honest assessment of how I got so lax in my personal safety standards. To make that assessment and figure out the real cause of any incident or accident takes a deep dive into all the factors that surround the event. It can be hard, and when you’re looking at one of your own mistakes the process can even be a little brutal.
The good news is there’s a format that is used by many organizations in healthcare, industry, and aviation to get to the bottom of the causes of an incident, a way to find out the true root cause. I’ve talked about the formal process in this space before and it’s appropriately called a “Root Cause Analysis (RCA).” I’m a huge fan of this process in surgery and aviation. The value of the Root Cause Analysis process is that it leads to a real understanding of all the causes of an incident, the obvious ones and the hidden ones contributing to errors in complex systems. The National Transportation Safety Board is the poster child for the RCA process. I’ve always been amazed at the results of their thorough RCAs and impressed by completeness of NTSB final reports of accidents and incidents that they look into. They will drill down into an event going back decades if that’s what it takes to understand all of the contributing factors that make up the root cause(s) that led to an incident.
Any time there’s something that just could have gone better it’s worth the time and effort to do your own little personal RCA. It’s as simple as taking out a note pad, getting anyone else who was around on the phone, and asking yourself and everyone else “what happened,” and then ask five “whys” answering how it happened. Statistics (95% confidence level) say that by the time you answer the fifth “why” question you are at the root cause.
Next month we’ll wrap up the discussion of personal error management with a simple and user-friendly way to do your own RCA to figure out why something went wrong and how to make sure it never happens again. We’ll do a little RCA to dissect my incident and go through all the steps I did to understand my mistake and make my safety process more rigorous.
