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  • Robert Jenney, SMS Perspectives

What a way to run a railroad!

Aviation Safety Connection

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SMS Perspectives: June 2015

Helluva Way to Run a Railroad.

Back in 1932 a newspaper cartoon showed two locomotives on the same track speeding towards each other. A railroad employee observed the scene and the caption of his thinking reads, “What a way to run a railroad!” Over time the above title became the more popular saying that generally refers to discontent with the way a business venture is managed. The cartoon also points to employee awareness of an organization’s management misdeeds.

In recent years James Reason introduced the concept that there is an organization failure that can be found in any accident. If we consider Asiana Airlines Flight 214 that crashed while attempting to land at San Francisco International Airport (SFO) on the morning of July 6, 2013 it is easy to conclude that poor pilot performance was the direct accident cause. The Boeing 777-200ER was vectored to a straight-in visual approach to Runway 28L. Initially slightly above glidepath at 14 nm from the landing threshold, the cockpit crew failed to set up a proper descent and the aircraft was well above the 3 degree glide slope at 5 nm. The flight crew mismanaged the autopilot and then, in an effort to salvage the approach, turned the autopilot off and brought the thrust levers to idle. These dramatic actions predictably caused a too rapid descent rate and the aircraft ended up below glide path with airspeed decreasing. Low and slow, the attempt to go-around was much too late and the landing gear and aft fuselage struck the seawall with the impact resulting in fatal injuries.

The investigation concluded there were a number of organization weaknesses that contributed to the accident, most notably deficient pilot training policies, ineffective training methods and the failure to insist on adherence to established SOPs. To its credit, in the aftermath of this accident Asana Airlines hired an experienced chief safety officer at the vice president level to institute flight safety initiatives. But the story doesn’t end here. To its detriment, the airline failed to provide this new hire with the needed resources and management support for him to succeed in accomplishing meaningful results.

A very recent article in the Wall Street Journal1 chronicles the Flight 214 post-accident developments at the airline and the obstacles encountered when attempting to improve a company’s safety outlook. This article could easily serve as a case study on company culture in the aviation industry. Very briefly, in terms of structure, the chief safety officer has limited authority in that he does not head the company’s safety panel. Of key importance, the pilots are not using the hotline he established for anonymous hazard or event reporting. The pilots’ union “prefers to raise such matters through management-labor meetings.” The safety officer has been successful in expanding pilot training programs and tightening training requirements but success in other areas has been limited. Quoting a line pilot: “There’s not much he can do alone in his capacity as chief safety officer. Although he is an executive, his reach is quite limited. He is an outsider.”

It is not my intent to single out this airline for criticism. Rather, it is to use a known situation to highlight essential principles of safety management. This story illustrates the need for company involvement and support, the necessity for open communications to bring safety issues forward, and the value of anonymous reporting to encourage participation. Without these features a Safety Management System can only be of limited effectiveness.

The flow down of information and support from the top in terms of policies that are reinforced by visible action encourages the flow up of valuable information from those closest to the action. I suspect the worker in the railroad cartoon would have been a knowledgeable and willing participant if asked.

--Bob Jenney (

1”Is Asiana Undermining Its Own Safety Chief?” by In-Soo Nam, Wall Street Journal, May 25, 2015.

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