I often tell others that learning to fly should be a requirement for executives and professionals because of very common elements: planning, decision making and communication. Fail at any of these elements in aviation and ... you die (and perhaps your passengers).
Review any aviation accident, and more often than not there is no single element that doomed the flight, but a combination, or series of events that, when combined, create the ultimate failure.
I came close to personal observation of these aviation truths on Friday when making a "routine" business flight to Northern California.
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| Above the clouds, looking for traffic. |
My plane is based at Oxnard Airport (KOXR). It is a quiet airport. Camarillo just five miles east is far busier with many more operations per day than Oxnard. Usually, there is no more than one other aircraft in staging awaiting departure clearance, and more often than not it's just 41M.
Friday I arrived in the run up area and there was a Cessna Skywagon awaiting departure at the hold short line, I heard another Cessna, a 172, on ground control getting taxi clearance to the runway, there was a new Corvalis (a sexy, fast Cessna that formerly was the Columbia Aircraft line - controllers still call it a "Columbia").
And there were several aircraft in the traffic pattern doing touch-and-goes, and other practice maneuvers.
In other words, KOXR was uncharacteristically busy, particularly for a Friday morning, and there was a lot of traffic on the ground and in the air.
The Corvalis had obtained an instrument flight rules clearance for a short flight to Van Nuys (she received her clearance on ground frequency while I was still tuned in), and I was instructed to get in line behind her.
Clue number one that this was not a "routine" flight - the Oxnard controllers seemed a bit rushed, a little anxious and perhaps not quite paying attention to details, what with all of the aircraft in the air, and on the ground ready to launch.
I mentally noted this, but it did not register as anything to be alarmed about; my anxiety (at it's normally heightened level due to the fact of aviating) was not unusually elevated.
After the first couple of Cessnas were released, the Corvalis was cleared for take off. 41M was next and I received an immediate take off clearance, "no delay" as one of the planes doing touch-and-goes was on final.
I had advised Tower that my flight was west-bound. But as I was on my take off roll Tower advised, "41 Mike, right downwind departure approved."
KOXR controllers are used to me departing to the east for my bi-weekly missions to see Mom.
Clue number two that something with ATC was amiss.
As 41M left the ground and I retracted the landing gear I mic'd up KOXR Tower , in between other aircraft calls, and advised, "Tower, there may have been some confusion - I'm departing to the west today."
The controller jumped right in, "Sorry about that - 6641M cleared to depart to the west."
At 2,000 feet KOXR airspace jurisdiction ends. I was flying visual flight rules because there was no adverse weather en route (kind of like the entire California winter...). I almost always, however, get Flight Following which is when Air Traffic Control assigns a unique transponder code so they can track your flight to the destination and provide traffic alerts en-route along with other safety communications.
Just above 2,000 feet I switched radio frequencies to Point Mugu Approach on 124.7. That frequency was likewise uncharacteristically busy, and every time I tried to mic in to get Flight Following services I would get trumped by another aircraft or by the controller. Communications were occurring lightning fast and aircraft that had already established communications with ATC get priority.
The Corvalis was on an IFR plan, and I noted had been getting vector assignments by Mugu Approach, which is normal practice. I tried to keep a mental picture of where that aircraft would be in relation to 41M.
In aviation this is called "situational awareness."
6641M has a traffic "radar" system aboard, called a Ryan TCAD (Traffic and Collision Avoidance Device). It is a invaluable piece of equipment that has saved my bacon on innumerable occasions when other aircraft get too close and ATC fails to call it out. I rely on the Ryan TCAD in busy airspace, particularly when I travel around the Los Angeles basin. Traffic picked up on the TCAD is graphically displayed on 51 Mike's Garmin 530 multi-function navigation/communication computer.
During the climb out I zoomed in the display of the Garmin 530 so I could "see" traffic near me.
Sometimes, though, an aircraft may not display on the TCAD enhanced 530 even if they are "squawking" a transponder code.
As I was climbing out west-bound through 3,500 feet, trying to get a call into Mugu, I heard the Corvalis pilot exclaim, "Mugu, there's an aircraft heading straight for us!"
I knew that was me. The Corvalis was not showing on the Ryan TCAD. I did not see any aircraft at my twelve o'clock. Fortunately my habit is to keep the landing light on when climbing out and the Corvalis pilot obviously saw that bright light ... getting far bigger and brighter than she would have preferred to observe.
Keep in mind that when an aircraft is flying IFR it is ATC's job to keep other aircraft away from it.
Mugu Approached excitedly called up with rapid speech, "Columbia [tail number], traffic alert, twelve o'clock, 3,700 feet, appears to be climbing, I'm not talking to him."
Just as Mugu said "I'm not talking," I saw out of the corner of my eye the Corvalis pass right underneath 41M - WAY too close for comfort, for anyone involved.
I think the controller was stunned into silence - for the first time in those precious climb out minutes there was a break in communications on 124.7.
I chimed in: "Mugu, Bonanza 6641 Mike - I'm the aircraft the Corvalis saw."
The controller responded, "6641 Mike, did you have a visual?"
"No visual, Mugu," I responded, "and no aircraft showed on my radar."
Shortly thereafter, the Corvalis received a vector instruction from Mugu and she headed off to Van Nuys, and I got a squawk code for my trip to Chico, CA.
No harm, no foul. But it took the better part of that 2 hour, 20 minute flight for me to settle down, and I'm sure it took the Corvalis pilot's nerves some time to settle too. Likely the controller also had to take a break.
There's risk in everything we do. Life is, by definition, risky. We do everything we can to manage risk, and this requires planning, decision making and communication.
Like aviation, workers' compensation administration is a team effort. There are people that calculate the risks, and what it will take to sufficiently manage those risks. Others sell the product that the people who do the calculating come up with. Still others are responsible for dolling out money and services when a risk does occur. And there are teams of other people who deliver medical and legal services and goods, among other tasks.
The tight coordination of all team members, including the employer and injured worker, generally results in what we would consider a good outcome - good outcome of course is a relative concept depending upon the nature and severity of the risk that occurred.
Plans are created, decisions are made, and communication of those decisions to the people that need to know - all necessary elements of a successful workers' compensation program.
Sometimes, though, certain members of the team get overwhelmed, or there is too much "traffic" to manage and consequently things go awry.
And sometimes those things don't show up on our radar in time.
I recall when I was still practicing work comp law a "disaster" file that I inherited. It seemed that everything in the file resulted in the wrong result. There were mis-communications, there were no plans, and the decisions that were made were a consequence of these errors. The file had been through multiple adjusters, attorneys, doctors - you name it, seems like all team members had changed several times through the course of the file.
The file was a simple back claim that had mushroomed into a skin and contents claim - every step of the claim resulted in something worse occurring. It wasn't all the claimant's fault, nor just the adjuster's fault, or the doctors'... it was everyone's fault. Everyone of the claim had failed in at least one of the three necessary elements.
The case had been through a dozen adjusters, as many physicians and therapists, probably nearly as many attorneys, and on...
After my review the adjuster on the file at the time authorized me to come up with a plan, which I thereafter prepared and communicated to everyone that needed to know. The plan was approved, and we began the execution of the plan - everyone had a part in the decision making process, including the claimant.
And after 6 months it seemed that the plan was working. The claimant was getting the services that we all knew were necessary to bring the injured worker back to some reasonable function (and maybe even back to work!), and it was clear that we were heading toward the light in the tunnel.
Then sight of the "Corvalis" was lost ... the file changed adjusters, again, and this time the adjuster didn't have the time, or take the time, to understand this huge, disaster of a file.
Communications stopped. Ergo, decision making became paralyzed, and the plan was not followed.
Shortly thereafter I left that law firm to start WorkCompCentral.
And a few years after that I visited the old firm to catch up with my friends, and to no surprise on my part, learned that the disaster claim was still ongoing, and had run amok once again. There simply was no continuity in claim handling.
I don't know whatever happened to that claim ultimately. I'm sure by now there's been some resolutions - after all it's been over 15 years.
Or maybe not.
Like Friday's flight, the signs were there. I was fortunate to have picked up on those signals during my short tenure on the file. Unfortunately, the rest of the team didn't see that plane coming straight at them.
And it costs everyone dearly.
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