Sharing ideas on Risk, Human Performance, Teams and Leaders

Wrong Side or Wrong Site?

Published: Wed 27 Mar 2019
This week we were treated to the news about a BA flight that took off from London and ended up in Edinburgh instead of Dusseldorf, Germany.

I will assume that this is a SUI or “never event” for the airline. Passengers will have been inconvenienced greatly and their reactions will be dictated by numerous issues including the impact of a few hours delay before the error could be rectified.

Wrong site incidents are not unknown in the airline industry although they make headlines when a plane has passengers rather than just cargo and the airline involved is a leading airline. There then followed an amusing twitter exchange with Ryanair which reminded readers that they too had their own wrong site incident a few years ago in Northern Ireland. Surely, the point is being missed!

The reality is that passengers were taken to somewhere they were not expecting and didn’t want to go - an adverse incident in anybody’s language. What matters is that the passengers are managed correctly, by the airline involved because those hours of delay and the incident may have had a greater impact on individuals than we can ever know.

Predictable events?

Such events are predictable and usually involve a combination of human and systemic factors. There will almost certainly be failures of communication not just within the back room but also on the flight itself. Did anyone speak up when they became aware that the flight was going north instead of South East. What were the cultural issues involved?

How might it have happened?

One of the factors that may have allowed this event to occur was that the aircraft operating the schedule had been ‘wet leased’ from another airline by City Flyer who operates the Dusseldorf flights from London City airport. A ‘wet lease’ means that the host airline pay a certain fee to the leased airline who then operate the schedule with their aircraft, pilots and cabin crew. The operation as well as all the legal paperwork will be flown under the Operations Certificate of the leased airline. One possibility is that BA City Flyer initially asked the leasing airline to operate the schedule from London City to Edinburgh and then at some point between setting up the lease and operating it there was a change of plan whereby BA City Flyer wanted the leased aircraft to operate the flight to Dusseldorf rather than Edinburgh. Poor or non-existent communication may have resulted in the operating staff never made aware of the alteration and thus continued to operate to Edinburgh.

A second mystifying fact is that none of the cabin crew on board the flight noticed that all the passengers would have had boarding cards showing Dusseldorf as the destination. And finally one might have expected there to be passenger addresses from both cabin crew and pilots mentioning the destination as Edinburgh. However either these passenger addresses were not made or nobody thought to question the content with the crew prior to take off? Regardless of the causes we can all learn.

What is there to learn?

These incidents can be planned for even if you can’t predict when or where they will happen. That plan should also include how you respond as an organisation and where that focus should be.

Looking forward to hearing from Captain Antonio di Lieto who wrote the book ‘Costa Concordia - Bridge Resource Management and talking on the Genoa Port fatal accident..

The value of the conference is that we learn from others rather than getting misled with the fallacy that “it couldn’t happen in my organisation”.

Authors: Guy Hirst & John Tiernan