On the 27th of October 2018, Agustawestland AW169, a twin engine helicopter, took off from the King Power Stadium, the home of Leicester City Football Club. On board, along with the pilot and 3 other passengers, was Vichai Srivaddhanaprabha, a 60 year old billionaire and the owner of the Leicester Football Club. He had just watched his team draw 1-1 with West Ham.
The helicopter took off from within the stadium and as the pilot turned the helicopter towards its en-route heading, the tail rotor control linkage broke, which is classed as a mechanical failure, sending the helicopter into an uncontrollable spin. One witness described the aircraft falling "like a stone to the floor". It struck the ground in stadium Car Park E, about 200 metres from the stadium, and burst into flames. Two police officers and club staff leaving the stadium attempted to rescue those in the helicopter but had to retreat due to the heat and flames. Tragically, everyone onboard was killed.
This is quite unusual because only 3% of helicopter fatalities are due to mechanical failure, the other 97% are pilot error.
To take off from a football stadium, the helicopter has to take off vertically, and although most people don’t appreciate this, helicopters don’t normally take off vertically because it is deemed quite unsafe. If an engine were to fail in a rare occurrence while taking off vertically, it is very difficult, if not impossible to land the helicopter . Therefore, helicopters normally take off along the ground like a plane. They skirt 6ft above the ground until they reach a certain speed before gaining altitude.
However, this helicopter was allowed to take off vertically because it has two engines.
Being a helicopter pilot myself, I take a keen interest in events like this. Not out of morbid fascination but because I want to be safe, and the best way to do that is to understand how these accidents happen so that you can avoid them, keep yourself and your passengers safe, and so people will trust you enough to join you on a flight, especially given that 97% of accidents are pilot error as opposed to mechanical failure.
This crash was unusual, being caused by a mechanical failure. I was talking to a fellow helicopter pilot the other day, and he was giving me some background on the accident. One of the things that struck me was that he described the issue not as “mechanical failure” but a “design fault”. I asked what he meant by this, to which he explained a nut had come loose on the back of the tail rotor, this nut had caused the problem. Some nuts on helicopters have a pin put through them with a wire on it so that they can never come loose and other nuts don’t have the wire through them. Obviously, this nut hadn't had a wire through it and so therefore, it came loose. This was deemed to be the cause of the crash.
What was interesting was his attitude in that by describing it as a design fault rather than mechanical failure he was basically implying the accident was avoidable not unavoidable. He was basically refusing to accept this was not an inevitable outcome.
As a result of this incident, it wasn't just accepted that ‘accidents happen’. Every single one of these helicopter models was recalled and the design of the tail rotor was amended, so as to ensure this accident could never happen again. The way in which future helicopter designs are approved was also amended.
It is very much the approach in aviation, whether it be pilot error or mechanical error, whenever an accident happens we look at what went wrong, then embed new measures to the systems and processes into the industry. Whether it be amendments to training or perhaps a design overhaul, whatever the decision may be, we embed that back into the industry so that an incident of that nature can never happen again. This is why helicopter travel has become so incredibly safe, despite the fact that these accidents receive such massive publicity.
At the time, this helicopter type was the only helicopter to have ever had an accident.
Is the aviation industry special? Why don’t we all act like this in business? And why is it so difficult for us to react, follow through and improve?
We often see mistakes in our business, we record them, we observe them, but it seems really difficult for us to mitigate the risk of the incident happening again?
We often identify solutions, whether that be over the watercooler or formal meetings, it often becomes very difficult to embed those things back into the business and make them stick. The aviation industry is really good at this, why can’t we all be?
For me the only way to embed change into a business, to make sure when you discover room for improvement and want to ensure a mistake doesn’t happen again, is through not only having really good documented processes but making process and change part of your company’s culture, something your organisation lives and breathes. A mechanism for collaboration and creativity, not just a way to ensure compliance and apply rigor.
Why is process seen as a dirty word? A word that fills people with dread? Slows things down and leaves little room for free thought?
The common mistake, processes are typically treated as paper that sit in files on shelves or on a share drive, documents that show how things are currently performed at the time they are written and then nobody ever looks at.
Processes are really something that an organisation lives and breathes, and should be embedded in the business on an everyday level. Especially, for the key things that make a huge difference, where processes are complicated, involve many parties needing to collaborate, and where those processes in the case of social care, can actually cause harm to individuals if we get them wrong.
Take the recent news regarding the Covid test lab in Wolverhampton being suspended for sending out wrong test results to around 43,000 people. This isn’t the first time the NHS has come under fire for producing wrong test results. In 2017 an NHS Trust had a series of wrong blood in tube (WBIT) incidents in their maternity unit. Incidents like this can occur when blood samples are taken from patients and are either miscollected (blood is taken from the wrong patient but labelled with the correct patient details) or mislabelled (blood is taken from the intended patient but labelled with the incorrect patient details). In 2018 the same Trust had a further four WBIT incidents in the maternity unit.
So why in 2021 are we still issuing wrong test results to thousands of people? Could it be that the very process which when first created, streamlined the task it set out to detangle, is now out of date and allows little room for staff to apply common sense and hasn’t been updated to fit the ever changing environment in which it serves.
If we change our perception of process, removing the fear and embracing change, empower staff and give them the tools to take ownership of process, create a mechanism where the process can evolve over time, then I believe we could see a radical change in the quality of all our service offerings and this could be the start of something great!