Safety and Justice/Teaching the system
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Teaching the system
Operators in the field often walk around with their "little black book" in the pocket of their coveralls. This little black book is a notebook in which they keep their personal notes about what to do but also, very often, how to do certain things. These are often little gems of knowledge but, on the other hand, can also sometimes lead to problems. An operator may have notes about "how to operate a certain system" in his black book, but when the system changes without him knowing these outdated personal instructions may lead to risks.
One day, it came to our notice that one particular operator had particularly intricate notes. It turned out that he had a real talent for understanding how a system worked, and for making diagrams that easily explained to an operator how a system worked, what the safest way of operating was. His schemes were much better, and much more appropriate for operators than all the other drawings around. These schemes were reviewed by the engineering team, given an official status, and have now been put together into the "Operators Almanac" which now is carried by the operators... in the same pocket as their little black book!
Telling about it
The pilot wrote an article in the safety magazine for his colleagues how he misheard the heading for flight level clearance. Instead of turning to heading 080 ("Turn right heading zero eight zero"), he CLIMBED his aircraft to flight level 080 (as if he had understood "climb flight level zero eight zero"). Thus his aircraft came into conflict with an aircraft that was descending to FL070 and this had to be solved by ATC. In hindsight, the pilot agreed that he mistakenly took the heading for a flight level and wrote extensively about this in the safety magazine of his airline company.