The Report Nobody Wants to File

Every Fix Starts With a Story

Next time you see a fuel truck on the ramp, look for the orange cone next to it.

There’s a reason that’s there.

I know… because I am that reason.

A Wet Night in Seattle

In 1998 I was a First Officer on the 737, in my probationary year and based in San Francisco. We were in Seattle for the last leg of the day, headed home to SFO. It was about 10 at night, cold, and raining.

I was doing the walkaround. The fuel truck was parked in front of the right wing, and as I passed it, the fueler handed me the fuel slip. I took that as a sign he was finished and about to drive off. I said thanks and kept going.

I walked the leading edge out to the wingtip and started back along the trailing edge toward the fuselage. The terminal lights were mounted high and pointed at the airplanes, so they were shining straight in my face above the outline of the fuel truck. With my eyes in that glare and the truck casting its shadow across the ground, the ramp under my feet was all but invisible. Pitch black and wet. Between the rain and the cold, I was squinting and just trying to get through the preflight.

I was looking up at the flip down landing light on the 737-300 when my right foot didn’t find the ramp. The hose had been disconnected, but the lid on the fuel access manhole was still open.

The Fall

My foot caught between the standpipe and the rim. I was already falling forward, and I could feel the edge of the opening against the middle of my shin. I remember thinking my leg was about to break. Then my foot came free, and I landed full force on my left knee, my hands, and my chest. My knee hurt, and the backs of my hands were bleeding and covered in oily ramp grime.

I finished the preflight, got cleaned up in the cockpit, and decided I could fly the one leg home as pilot monitoring. I saw a doctor the next morning and filed the on the job injury paperwork. I was out for six weeks with leg and knee injuries.

The Phone Call

That could have been the end of it. Nobody wants to write up the night they fell on their face on the ramp, least of all a probationary First Officer. My whole goal that year was to get through probation without any issues. Well, I certainly had one. I filled out the paperwork because I had to, and it recorded what happened to me. But it didn’t change anything on the ramp.

During my recovery I got a call from the safety people, ALPA if I remember right. We talked through what happened, and he asked if anything could have prevented it. I thought about it and told him that if something had been sticking up, like an orange traffic cone, I would have seen it and stepped around the opening. No fall, no injury.

He said, “That’s a great idea.” By the time I came back to work, it was in place systemwide.

What Made It Work

This was 1998, years before anyone at an airline was talking about SMS. But the pieces that matter were all there.

Somebody read the report and followed up. They asked the person who was actually there instead of guessing from behind a desk. The fix was cheap and simple, and it targeted the exact failure: the hazard was invisible in the shadow, and a cone made it visible. And because the fix made sense everywhere, they didn’t stop at Seattle.

Nobody did anything outrageous that night. The fueler handed over the slip, which told me he was done. The lights were where the lights always were. I was looking up at the airplane, which is what you’re supposed to do on a walkaround. Each piece was normal. The cone breaks the chain at the one spot nobody could see.

Why It Matters

A reporting system is only as good as what happens after the report. My injury paperwork would have sat in a file. The phone call put a cone next to every fuel truck, right where its hose goes into the ground. If you run a safety program, the lesson is simple: follow up, and ask the person closest to the hazard what would have stopped it. Then use that momentum. Put real thought into a fix that works for everyone, and get it in place while the lesson is still fresh.

File the report. Make the call. Somebody’s next step depends on it.