How was This Mistake POSSIBLE?! FedEx Flight 1170

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Let's take a moment to appreciate the importance of a non-punitive incident reporting system. Some parts of the world still have some catching up to do in that regard.

Even for a large mistake, the crew still did a good job of acknowledging and reporting it, and that alone should be commended.

The way they handled this situation afterwards tells us A LOT more about these two pilots than the actual mistake. Professional, acknowledgement of mistake, honest.

When you first described the RAAS system, I immediately knew the flaw in it. In computer science (and there's a significant amount of research into human performance factors in human-computer interfaces) there is such a thing as notification fatigue. That's when you click away the popup without reading it because it has never been relevant before. In this way, the RAAS messages are ignorable - they are just a quiet message announced that usually has absolutely no consequences, and so that one time when one does have consequences it is likely ignored, as in this case. The solution is to make the messages more specific. Rather than waiting for a message "Approaching runway X" and getting the human to notice if X doesn't match the target runway (which gives vast opportunities for confirmation bias), instead have the fallible human tell RAAS in advance what X is (eliminating confirmation bias), and then it can differentiate the announcement. If it matches, it can just say "Approaching runway X", but if it doesn't, it should announce loudly "Approaching incorrect runway Y, go around now".

Props to the CO for immediately saying, "We're writing independent, separate reports."

As a night shift RN (we work multiple 12+ hour shifts in a row), these incidents always hit a little too close to home. healthcare is definitely not as concerned as aviation about the effects of fatigue on its workers.

I like seeing these more obscure incidents where no one gets hurt and aren’t sensational but still offer a wealth of lessons.

As a retired FedEx captain of 36 years, (B-757, B-767, MD-11, A-300, B-727) your recommendations are spot on. Those were the rules I lived by during my career and it ended well for me. Excellent presentation as well.

"Guess we'll get to practice writing reports." It's actually a really good thing that you can think like that. Kudos to the company and the aviation culture for keeping it this way.

People make mistakes. Lapses in concentration or judgment are common. What matters is how they react; what they do afterwards to address and rectify the situation. These pilots were exemplary in that aspect. Respect.

I'm a physician and used to work as an oncology hospitalist on overnight shifts so the fatigue discussion was relevant to my job and also I watched disaster videos as part of training on recognizing errors and ways to mitigate them, I always found the parallels between acute care medicine and flights to be fairly related

Despite the obviously serious mistake, the way they handled the situation afterwards was very nice to see - saving the CVR and also deliberately not aligning their stories.

Petter: I am a retired middle school teacher (worked with 12-year olds) who has loved your YouTube work for years. Leaving aviation aside for a minute, you should know that you and your team are superb from a pedagogical viewpoint. In other words, you are a fantastic teacher here, and I am sure you are equally fantastic when coaching less experienced pilots in the cockpit.

As a Tower Local Controller, I was taught that once I issued a landing clearance, I was supposed to frequently scan the runway and the inbound aircraft to ensure the runway was clear of obstructions and that the aircraft was lined up for the correct runway. I continued that frequent scan until the aircraft was clear of the active runway. Great video Petter!

Non-punitive report system really does wonders for future safety. It's great when you feel like you can report some mistake or failure without being severely punished for it.

I loved working on this video. It was super interesting.

They handled the situation very professionally after realizing their error.

As a retired controller with decades of experience I can say single controller mid-shifts were the worst. Best way to stay alert was to remain standing and visually follow the few aircraft you given instructions to.

I am an EH&S manager in a factory and I'm able to refer to so many situations and responses from this channel, that can happen to well-trained people. We have tool box safety talks before every shift hoping to keep smart decisions in the forefront. We are 818 days safe so everyday is a new record! I use so much information from here to help my people stay safe! It's crazy how upset conditions are so prevalent in accident investigations and, in so many cases, people going above and beyond when they get hurt thinking they are doing the company a favor. Thanks for such an amazing new angle of being able to relate to my audience and make sure they leave work in the same condition they showed up in.