It Can Happen to Anyone

How a series of fuel management errors ended in an engine failure for an instructor and a private pilot on final approach at Rockcliffe

by Roger M. Delisle

Errare Humanum Est”, as was said nearly 2000 years ago: To err is human.  In this edition we look at how this timeless quote does not segregate among pilots. A recent incident at our Flying Club shows us how a chain of insidious events can creep up to catch even a well-intentioned, cautious pilot and an instructor off guard.  Thankfully no one was hurt and no damage was incurred in what will surely be an incident the two pilots will not soon forget.  In this first of two articles inspired from it, we’ll focus on the interesting series of coincidences that led to the incident and the safety defences that prevented a potentially serious accident. This look at the chain of events will use Reason’s Model, a safety tool that can help us understand the human factors in incidents and accidents and help prevent them.