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Heneghan: Black swan events

March 27, 2018  By Walter Heneghan

I recently started down a path that I first heard about in 2006, when I saw Professor Sidney Dekker speak at the Transport Canada Aviation Safety Seminar in Halifax. These seminars were a tremendous contribution to the Canadian industry and, for the life of me, I never quite understood why TC stopped hosting them.

Dekker, the keynote speaker at the seminar’s plenary session, was speaking about the new view of human error — that a finding of human error really marks the beginning of a safety investigation and not the conclusion — and why this concept was not only worthy of being broadly adopted by the aviation industry but also deserved further study. He had just founded the post-graduate degree program at Lund University in the study of human factors and system safety and was raising the program’s profile. I remember thinking that this course of studies would be an interesting pursuit, but also that Dekker would be a bear of a prof!

Well, I am now in the process of obtaining my post-graduate degree and for you this means some of my traditional diatribes about safety in our industry will be interspersed with tidbits from my academic pursuits. You may even get a tip or two about a great book to read, but I promise I won’t ask for assistance with my assignments.

Earlier this winter, I read with some incredulity about the quarantine of the sale of avgas 100 LL for fuel manufactured after Dec. 28, 2017. The quality control issue regarding the product from the Strathcona refinery raised an interesting point: how could an operator possibly risk-manage an event like this?

Certainly, from a mitigation perspective, grounding your aircraft until you can confirm fuel quality is a no-brainer. Inspecting and testing your fuel stock is a clear requirement. Communicating with the fuel supplier to fully understand the quality control concerns would be the logical next step.  And finally, sourcing a clean supply to get back into business would likely take up a lot of your attention. But, from a planning perspective, I am willing to venture that very few (if any) companies would have foreseen such a blanket halt to AvGas sales in any risk management planning sessions. So, how should we risk-assess these types of seemingly “black swan” events?  


Black swan events came to life in Nassim Nicholas Taleb’s books,  Fooled by Randomness, which concerned financial events, and The Black Swan, which extended the metaphor outside financial markets. A black swan event has three common attributes: it is an outlier, beyond the realm of regular expectations; it carries an extreme impact; and, after the fact, we create explanations that make it explainable and predictable.

This national quarantine of avgas seems to fit into this definition. That it does so is of little solace to those flight schools and small charter operations who have to shutter their operations (and their cash flow), due to something completely out of their control.

But, as risk managers and safety professionals, we can learn a valuable lesson from this event. Spring is when we prepare for the upcoming season, completing pilot, dispatcher and AME training, lining up contracts and finishing annual inspections so that we can  concentrate on staying safe and making money in the summer.

This is also the time of year, during a period of low flying activity, to sit with your crews and managers and reassess your operations from a risk and safety point of view. What are the identified hazards in your operation? Are the risks associated with the hazards properly assessed? Are your controls in place to manage the risk? Are your mitigation measures sufficient to minimize the impact of an event? Now, on top of that, and in light of the fuel quarantine, I challenge you to consider what else can hurt your people or impact your operation and business.  

As former U.S. Secretary of Defence Donald Rumsfeld became famous for saying in the context of Saddam Hussein: What are your unknown unknowns? Where are those vulnerabilities to your business that could have severe or catastrophic consequences, but that you have not yet thought about? Do not wait for the black swan to arrive. Own your process, think out of the box and get prepared for the next national fuel quarantine.

Walter Heneghan is an experienced and well-travelled pilot who has served as the top safety professional at Canadian Helicopters and Summit Aviation. He is currently working with CHC Helicopter in Kazakhstan as an SMS development specialist. He is a regular contributor to Helicopters and Wings magazines.


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