Lessons learnt when Ryanair flight FR-9672 avoided a fatal collision

 

On 7 September 2005, *Ryanair flight FR-9672 from Germany to Rome avoided a potentially fatal collision that would have put the lives of 166 passengers at risk.

The incident occurred on a daytime flight from Niederrhain in Germany to Rome’s Ciampino airport. Midway through the flight, severe thunderstorms forced the captain to redirect the aircraft to Rome’s Fiumicino airport. 

In doing so, the pilot began missing air traffic control instructions, and started flying below safe altitudes, putting the plane at risk of crashing into other aircrafts. At one point during the incident, it descended below a safe height near hills. Air traffic tapes show the aircraft meandering above the airport and failing to line up with the runway. The pilot and his deputy made the decision to divert to nearby Perscara airport in Italy, where, finally, the plane landed safely.

An investigation was launched soon after. It found that the captain was psychologically unfit to fly because he had buried his three-month-old son days before and was too afraid to take extra leave because he feared losing his job.

This case study, presented by Ulrich Straub, risk engineer at Swiss Re Corporate Solutions, placed human performance integrity risk – the ‘human element’ that could affect critical performance – at the centre of discussions at StrategicRISK’s Dubai roundtable, held during the Dubai World Insurance Congress.

Attended by senior risk managers from critical-safety industries, including aviation, construction, oil and gas, and energy, the discussion focused on the challenges that risk managers face in identifying such risks.

Human error brought on by bereavement, fatigue, personal stress and overworking, for example, can hinder critical performance and inevitably negatively impact safety, quality, profit and security.

The case of Ryanair flight FR-9672 illustrates the power human emotions can have on performance. But, as risk managers at this roundtable found, identifying human error before it emerges, and creating systems and safety processes for preventing it, are strategic challenges.

At the heart of the challenge is corporate culture.

Empower staff to speak up

In many high-pressured and results-driven industries, there is a propensity to remain quiet about personal and emotional issues that could affect performance and lead to large-scale losses, said one risk manager who works for an airline company.

“How do you ensure that all members of staff are fit to work? I have young children and when they are sick I will often be kept awake throughout the night, with very little sleep. I will suffer fatigue but will I speak up?

“This is a corporate culture issue. Companies need to foster a culture that enables employees to raise such issues and feel comfortable with saying, ‘I haven’t slept much because my children are ill. Can someone cover me, and can I be deployed in a position that isn’t safety critical?’

“Employees, particularly those in critical-safety roles, have a responsibility to do this. But it is the manager’s responsibility to ensure the right culture exists for staff to speak openly.”

For many businesses, production is often prioritised over safety. This is an inadvertent trade-off: profits and volume capture the board’s attention – much more so than human performance integrity risks. And so, the primary focus across the company will be on profits above all else, said a risk manager from a metals and mining industry. “We’re human not robots. So, the ‘human element’ in risk will always be a factor that businesses need to manage.

“From an enterprise risk management perspective, the human factor should be something that everyone is talking about. This ensures that people-related risks can be prevented and mitigated. It is a corporate culture issue – and we need to effect change.”

Solutions are out there

There are, however, examples of good practice. The construction industry appears to be flying the flag in managing human performance risk, with innovative solutions using wearable technologies.

Biometric and environmental sensors are fitted into protective equipment such as hard hats, gloves, safety vests and work boots.

These sensors monitor and capture data on workers’ movements, repetitive motions, posture and slips and falls; as well as heart rate, body temperature and other vital signs. The device will alert safety managers of any members of staff who are suffering from issues such as exhaustion, overheating and fatigue – conditions that if mitigated will prevent thousands of injuries on construction sites each year. 

The risk manager whose organisation piloted the device has seen positive results. “Through algorithms, we were able to identify workers suffering from sleep apnoea,” he said.

“We found that they were only getting four hours’ worth of sleep. We got medical professionals in to address the issue. This really helped to eliminate issues of being afraid to speak up. It also demonstrated that we have a positive attitude and that staff will not be penalised for suffering a personal issue.”

Cultural change is, ultimately, a key solution to addressing human performance integrity risk – certainly in the long term. But as in the example of wearable technology, tools and services are emerging that can help better manage risk and engage workers in the safety process, in the short to mid term. This is explored further in our Expert View, below.

As for Ryanair flight FR-9672, fortunately this was a near-miss. The pilot lives another day to tell of the lessons learnt. And what are they? For one, to never underestimate the human factor in a potential loss event.

 

*Source: Flight International