Operators in the field often walk around with their "little black book" in the pocket of their coveralls. This little black book is a notebook in which they keep their personal notes about what to do but also, very often, how to do certain things. These are often little gems of knowledge but, on the other hand, can also sometimes lead to problems. An operator may have notes about "how to operate a certain system" in his black book, but when the system changes without him knowing these outdated personal instructions may lead to risks.
One day, it came to our notice that one particular operator had particularly intricate notes. It turned out that he had a real talent for understanding how a system worked, and for making diagrams that easily explained to an operator how a system worked, what the safest way of operating was. His schemes were much better, and much more appropriate for operators than all the other drawings around. These schemes were reviewed by the engineering team, given an official status, and have now been put together into the "Operators Almanac" which now is carried by the operators... in the same pocket as their little black book!
Aviation specialist focused on SMS with pre-emptive risk management. An impeccable record in court as expert witness.
To my later embarrassment I once severely chastised a young pilot at the squadron for landing a military T6 trainer wheels up. The very next day I was distracted by the control tower twice - first just as my hand went to the left side of the cockpit to lower the gear and I pressed the PTT on the throttle, and then again to feel the gear lever in the down position.
I was instructed to extend my downwind leg in the pattern and the ATC kept up a constant review of a Mach2 fighter in an emergency pattern, low on fuel. Eventually I turned final, keeping a look out for the Dassault Mirage III. Then I realized I was staying high in my approach. Also there was on top of the babbling ATC a very annoying noise in the cockpit, which finally proved to be the landing gear warning horn that sounded as I reduced power to regain a stabilized approach. By taking away the horn in order to hear the ATC I kept the power up.....
On short finals I decided to take power and go around and do another hopefully perfect approach and then, when I wanted to raise the gear I realized it had never been lowered.
After a perfect second approach and with a bad stomach I landed and went and bought the young chap a coffee and apologised to him and explained the whole sequence of my own near smear onto the runway. A lesson for both of us.
The pilot wrote an article in the safety magazine for his colleagues how he misheard the heading for flight level clearance. Instead of turning to heading 080 ("Turn right heading zero eight zero"), he CLIMBED his aircraft to flight level 080 (as if he had understood "climb flight level zero eight zero"). Thus his aircraft came into conflict with an aircraft that was descending to FL070 and this had to be solved by ATC. In hindsight, the pilot agreed that he mistakenly took the heading for a flight level and wrote extensively about this in the safety magazine of his airline company.