Consequences 6.2

Consequences

Hey! It's your man again! Does he have a problem following the rules? Have you established his competence for the job? Who trained him? Did you make sure the procedures were clear and unambiguous and fit for the job?

What are you correcting:

If the same person is found deviating from known rules and procedures an number of times, you need to go a little deeper. It could be that your training methods are not effective or that rules and procedures are too complex. On the other hand, it could be that the person simply misses the competency to be able to operate at the required level or that there is is bigger issue related to his or her attitude. In these cases you need to address how it is that people that do not meet the competence levels are put in this position, or you need to address the issue of professional attitude. When it comes to professional attitude, a key thing to observe here is the person's reaction to being corrected. Being corrected can be painful, and you need to take that into account, but if somebody is open for this correction there is usually not a real problem. If somebody refuses to be open for this correction however, the problem is more serious and it might well be that this is a more serious case.

How are you correcting:

At this point it is important to address the issue completely and deeply. What is the pattern here? Take a person out of the operational proces until you either feel confident that he or she has demonstrated the competence and/or attitude that give the organization the confidence that he or she can function again.

Be mindful of the fact that you are not talking to an evil person here: we all sometimes struggle to learn something, and we all fall into the temptation of ego sometimes (be honest!). But low competence and pretending to be better than you are, or better than your peers or superiors, simply has no place in a high reliability team.

Take a critical look at your training and selection process. Check your supervisor's ability to handle ego-related issues or to judge somebody's competence correctly and fairly. It is not fair or "nice" to put somebody in a job that is above his or her competence!

Wrong intersection

The crew crossed the runway at number W11, in stead of continuing to taxi all around the runway at the south end, using taxiway Zulu, as they had been cleared to do by the traffic controller.

This certainly was not the intention of the crew. But what they found perhaps confusing, was that the tower controller cleared them "to cross 36C at Zulu". Although the wording "Zulu" could not possibly be misunderstood about where they were supposed to be (Z->Z2->Z1->Z), it was the word "cross" that confused them. To them, this meant they had to physically be on the runway to "cross" it. But in correct ICAO language, the word "cross" is also used when the aircraft needs to taxi around the south end of this runway and needs to cross the holding line at Z2.

In a telephone discussion between the controller and the captain, the controller pointed out to the captain that there was an extra sheet of paper in the airport diagrams, laying out this particular "hotspot" situation. Over the phone the controller heard papers shuffling and then the captain sigh "Oh.. .buggars... If I had seen that, I would have never made this mistake"

Many solutions have been tried to solve this. In the end, the aiport physically blocked both entries W12 and W11. End of problem.

Consequences

Examples Rule not Followed

Wrong intersection