SAFETY PERSPECTIVES

Tragedy Over South American Skies – A Case of Safety Risk Tolerance?

Posted by  Esteban Tristan, Ph.D.

safety risk tolerance

On November 28, 2016, LaMia Airlines Flight 2933 took off from an airport in Bolivia in route to Rionegro, Colombia. Among the 73 passengers on board was Chapecoense, a Brazilian soccer league team, who was scheduled to play in the first leg of the 2016 South American Cup Finals in Medellin, Colombia. The flight departed at 6:18 PM local time. Less than four hours later, all but six of the passengers and crew were dead after the aircraft rapidly descended and crashed into the crest of a mountain about 20 miles away from its destination. The main cause of this tragedy? The plane ran out of fuel, according to the findings of the crash investigation. This was quickly evident to investigators and those who first arrived at the scene due to the fact that there was no fire or explosion upon impact. Black box recordings and statements by the lone surviving crew member supported this as well; the final words the crew remembers hearing the pilot say were, “There’s no fuel left.”

So yes, it ran out of fuel. How could this happen? As with any fatality or significant incident, there were precursors, contributing factors, and behavioral patterns that led up to this. However, many of these seemed to have a common thread – safety risk tolerance. For example, the crew’s flight plan revealed that the aircraft’s planned fuel range was almost equal to the total flight distance. In other words, there was literally no room for error. If the flight were to require even a slight unexpected delay, such as a holding pattern, it would have been very clear that the aircraft would likely run out of fuel. It was found that prior to the flight, the pilots had considered possible fuel stops along the way, but since the crash site was so close to the final destination, it appears they decided against a fuel stop and felt they could make it. So they were cutting it close, but why didn’t they make it?

Unfortunately (as often happens when we push the limits) the unexpected did occur. When the pilot first reported low fuel and requested to land, air traffic controllers at the nearby Medellin airport instructed them to enter a holding pattern and wait with three other aircraft because another flight was being diverted there from its initial route. After completing two of the four holding pattern laps and using another 54 nautical miles worth of fuel, the crew reported an emergency as two engines flamed out, followed by the other two engines. At this point, the flight data recorder stopped and the aircraft smashed into a mountain called Cerro Gordo at an altitude of around 8,500 feet, killing 71 passengers and crew members.

As I mentioned earlier, however, there was a pattern of risk tolerance at LaMia. Consider the following set of findings from the crash investigation, which included 23 investigators from Colombia, Bolivia, the U.K. and the U.S:

  • The investigation found that LaMia Airlines had a history of pushing the limits with fueling practices. Records indicated that in over one-third of its flights over the previous four months, fuel and loading regulations of the International Civil Aviation Organization (ICAO) were violated. Specifically, eight of 23 flights in that time period would have had to use at least some of the aircraft’s mandatory fuel reserves. This is a dangerous practice and clearly indicates that LaMia pilots were accustomed to pushing the limits of fuel reserves during their flights.

  • The initial flight plan was actually – surprise – rejected! Officers at the Bolivian airport rejected the plan more than once because of the obvious risk of fuel exhaustion. However, LaMia had friends in high places. In fact, the airline’s Director General was detained on various criminal charges including involuntary manslaughter when it was found that his son, who worked for the General Directorate of Civil Aviation (DGAC), used his position of influence to pressure key airport officials into approving the flight plan which was initially rejected. In the end, he won, and the flight plan was approved and dooming the passengers on board.

  • The aircraft was also found to be overloaded by nearly 900 lbs. Fuel policies were not the only rules that LaMia ignored – pushing the limits with weight was also deemed to be an acceptable risk, which may have further decreased the aircraft's flight range given its extremely limited fuel.

Sadly, this is just one of many fatal accidents that can be attributed, in part, to overconfidence or high-risk tolerance. We have seen this type of fatal and flawed decision-making in the oil industry, in chemical and nuclear power plants, and of course, in the airline industry. But, as I read the stories and accounts, what struck me about this particular story was how high and how clear the risk level appears to be from an outside perspective. Furthermore, when you think about the amount of control and responsibility that a pilot has and the many lives that depend on their actions, it is easy to assume that I would never take that kind of risk, in that situation.

But psychology and incident investigations tell us that it’s not that simple. It’s impossible to know exactly what the crew’s perspective was and the situational factors they were dealing with at the time. They were flying a well-known soccer club to an important playoff game – was there significant pressure to get the flight out that night? The pressure from the General Director’s son to get the flight plan approved tell us that this was likely the case. What was the financial situation? Money may have been tight and perhaps they were under orders to save costs on fuel? But most importantly, cognitive bias likely played a huge role in this event. As records showed, crew members had pushed the fueling limits many times before and nothing happened. They landed just fine, without any incident, and probably without anyone noticing. This type of bias, based on past experiences, can lead even the most rational thinkers to make risky decisions that put them and others in harm’s way. It’s usually not apparent to them until it’s too late (Krause, 2005).

So, situational factors play a huge role in decision making and risk. But are all individuals the same when it comes to risk tolerance? While we are all susceptible to cognitive biases under the right conditions, research on personality traits for years has shown that there are large and statistically significant differences across the population when it comes to risk tolerance, risk-seeking, and impulsivity. In other words, there is an aspect of risk tolerance that is related to stable personality differences. We are not all equal when it comes to risk. Furthermore, studies show that people who have high levels of risk tolerance tend to have more at-risk behaviors, driving violations and work-related injuries (Christian, Bradley, Wallace & Burke, 2009; Paul & Maiti, 2007; Arnett, Offer, & Fine, 1997).

What does this mean? That it’s complicated. It’s the situation AND the person. My belief is that we do not live or work in a vacuum, but we also are not always at the mercy of things that happen around us. There has to be some level of ownership in our decisions when it comes to acceptable risk. In order to better understand human decision making and risk, we must always account for as much information as possible, and that means we must always look at both sides of the risk tolerance equation.

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References

Arnett, J.J., Offer, D., Fine, M.A. (1997).  Reckless driving in adolescence: State and trait factors.  Accident Analysis and Prevention, 29, 57-63.
Christian, M.S., Bradley, J.C., Wallace, J.C, & Burke, M.J. (2009).  Workplace safety: A meta-analysis of the roles of person and situation factors.  Journal of Applied Psychology, 94, 1103-1127.
Krause, T. R. (2005). Leading With Safety.  John Wiley & Sons: Hoboken, NJ.
Paul, P.S, & Maiti, J. (2007).  The role of behavioral factors on safety managements in underground mines.  Safety Science, 45, 449-471.

Tags:   SafetyDNA, safe behavior, safety commitment, safety communication, safety culture

Esteban Tristan, Ph.D.

Esteban is the Director of Safety Solutions at Select International. He manages the development and implementation of all safety solutions and services, which address some of the critical challenges faced by organizations today in workplace safety.

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