Back in May 2018, I had the privilege of being a guest presenter at the IATA Cabin Operations Safety Conference in Bangkok, Thailand. My topic was something I strongly believe in, and that is looking into the root cause of what went wrong. This does not mean crewmembers are innocent from their mistakes, but don’t necessarily rush to judgment and immediately fault the crewmember. The question is, was it the crewmember, or was it the system that erred.

Flight attendants spend weeks going through initial training, then go out and operate in accordance with the training program. We all know the flight attendant manual does not cover every single scenario, and when we train flight attendants, we expect them to use both common sense and experience to determine how to handle various situations that happen on an airplane. There’s no doubt that some people are just not meant to work as a flight attendant; they don’t have the necessary people skills or sharp thought processes to be successful as a flight attendant. However, there are times when very good flight attendants make an error, be it through lack of attention or lack of judgment, and now management needs to speak with them.

Often, the initial knee-jerk reaction is to find out what the flight attendant did wrong and determine what consequences are suitable for the infraction. Yes, some people do not deserve a second chance and should be let go, or some people do deserve the punishment because their actions were deliberately negative. But what about the flight attendant who did their best based on the circumstances, but is not the outcome that in-flight management expects or usually tolerates? Is it always 100% flight attendant’s fault for the actions they took? I don’t believe so, and when things go wrong, this is actually a good time for an internal inspection of the in-flight operation manual and training program.

Fact gathering is a must to help determine what went wrong and why it went wrong. Often we can see through someone trying to cover themselves versus someone who innocently made a mistake. Sometimes an innocent mistake can be very costly, such as inadvertently inflating an evacuation slide upon arrival at the gate. Years ago, we were told during training, “if you ever forget to disarm your slide, the slide inflates and it wasn’t an emergency, you might as well grab your suitcase and go down the slide because that will be the last day you work as a flight attendant for us!” When things went wrong, the person was always addressed, but what about the problem?

Not always was the root cause addressed as the crewmember was seen as being the problem. This is not always the case.

Sometimes it is a failure of the system the flight attendant works within, meaning the flight attendant manual and flight attendant training program make up the system, and the system itself contains deficiencies.

“What’s wrong with the system? It’s perfectly designed, there is nothing wrong with it! The flight attendant made a mistake. We train them, it’s reinforced in the manual, the mistake should not have happened. They used bad judgment and that is all it is.” While I don’t encourage crewmembers to make errors, when things go wrong, I see that as an opportunity for improvement of the flight attendant manual and training program.

Some may think, “Why not just blame the flight attendant and address them?” The problem needs to be fixed, and blaming someone alone does not fix the problem. While it’s possible everything may have been in order and the flight attendant really made a mistake, this is the time to see where the system might have failed.

After performing a thorough investigation into the event, look at the manual and see if that type of situation well covered for the flight attendant to have had something to reference or learn from to create good judgment?

If the content is not there, the manual is deficient. If the content is there, is the information clear and easily understood? Next, take a look at the flight attendant training program. The manual may have been sufficient, but does the courseware address that same content in the same way? Does the course content have errors?

Who taught that class? Was the instructor new, or were they a well-experienced instructor? Are there any test questions on the subject? If yes, how have students scored on that question or questions? If no, perhaps questions addressing that topic should be added to the exam. There are many potential errors to evaluate and see if there are deficiencies in the training program.

Before addressing the crewmember and coming up with a punishment for the actions taken or not taken, do also take a moment to find out if the system contributed to the error made by your crewmember. Not always is it black and white. Often crewmembers want to do their best, but they aren’t given enough information or don’t have enough experience to refer to during decision-making. This is all part of the continual improvement of the Inflight operation.