Sydney Airport Near Misses: The Most Dangerous Words in Safety Are, "We Already Know What Happened"

The Jetstar A320 and Qatar 777 on the taxiway at Sydney Aiport

Over the course of just a few weeks recently, two serious safety events occurred on the ground at Sydney Airport. In one, a Jetstar Airbus A320 and a Qatar Airways Boeing 777 came into close proximity on a taxiway. In another, a Qantas aircraft was reportedly cleared to cross an active runway while another Qantas aircraft was still completing its landing roll. Fortunately, neither event resulted in a collision. With the exception of a member of the Jetstar cabin crew who suffered a minor wrist injury when the A320 braked suddenly, everyone else involved, at the airport went home safely that day.

However...... the investigations, had barely begun before something else predictable happened. Social media filled with opinions. Industry forums began dissecting the available information. Aviation professionals, journalists and members of the public all started asking the same questions. Who made the mistake? Was it the controller? Was it one of the flight crews? Was someone distracted? Did somebody misunderstand a clearance? Who do we blame?

If you've worked in any safety-critical industry for long enough, this pattern probably looks familiar. It doesn't really matter whether the event involves aircraft, a mine site, an operating theatre or a production facility. As soon as something significant happens, we instinctively begin searching for a simple explanation, a root cause. Uncertainty is uncomfortable. It leaves us feeling exposed. Our brains would much rather replace that uncertainty with a story, even if the story is incomplete, because stories help us make sense of events that otherwise feel confusing and unpredictable.

This article isn't about whether the pilots or controllers involved in the Sydney events made mistakes. At the time of writing, the Australian Transport Safety Bureau has only just begun its work. The evidence hasn't yet been collected, analysed or tested. Cockpit voice recorders, radio transmissions, surveillance data, interviews and operational procedures all need to be examined before anyone can responsibly explain what happened. The ATSB exists for precisely this reason. Their role is to gather evidence before reaching conclusions.

I'd like to use these events to provide context to talk about something different.

Rather than trying to explain what happened at Sydney Airport, I'd like to explore how leaders should think whenever an incident occurs, particularly when there is very little information available. A useful lesson I've learned through aviation and studying Human Factors isn't how to investigate accidents, it's how to resist the temptation to finish the investigation too early.

One of the challenges facing every leader is recognising that our brains are prediction machines. We don't simply observe the world around us. We constantly interpret it. As new pieces of information arrive, we fit them into existing mental models that help us understand what's happening and predict what will happen next. Most of the time this works remarkably well. It allows us to make rapid decisions, recognise patterns and operate effectively in complex environments.

Occasionally, however, it causes problems.

When an accident or near miss occurs, the information available during the first few hours is almost always incomplete. Someone posts a photograph. A short radio transmission appears online. A witness gives an interview. A journalist publishes an early report based on anonymous sources. None of those pieces of information are necessarily wrong, but none of them tell the whole story either. Despite this, we begin assembling them into a narrative that feels coherent. And once that narrative starts making sense in our simple brains, it becomes surprisingly difficult to let go of it.

You'll doubtless have experienced this in normal life: A colleague walks past without saying hello and we conclude they're annoyed with us. A friend doesn't reply to a message and we assume they're ignoring us. An email arrives with very little context and we immediately decide what the sender meant. Later we discover we'd completely misunderstood the situation, but for a period of time our version of events felt absolutely convincing.

Serious accidents investigated by the ATSB are not that different. The only real difference being the consequences of becoming convinced too early are often much greater. This relates to why Just Culture has become such an important concept in modern safety. Contrary to popular belief, Just Culture isn't primarily about protecting people from blame. It isn't about avoiding accountability and it certainly isn't about pretending mistakes don't matter. At its heart, Just Culture recognises something much more fundamental.

If we rush to judgement of people before we've understood the system, we dramatically reduce our opportunity to learn from it. The moment we become convinced that we already know what happened, our curiosity begins to disappear. Questions are replaced by conclusions. Evidence starts being viewed through the lens of our existing beliefs. Information that supports our explanation feels persuasive, while information that challenges it suddenly becomes less important. None of this happens because investigators are incompetent or because leaders are acting in bad faith. It happens simply because they're human.

A good investigation will deliberately slow the thinking process down. Rather than asking, "Who made the mistake?", they begin somewhere else.

What do we actually know?

What evidence supports that?

What evidence challenges it?

Perhaps most importantly, what assumptions have we already started making without realising it?

Professional accident investigators are willing to live with uncertainty for much longer than the rest of us because they understand something many organisations struggle with. Reaching the wrong conclusion quickly is often far more damaging than reaching the right conclusion slowly.

History is littered with events where the first explanation turned out to be incomplete or entirely wrong. Sometimes the final report confirms the initial assumptions. Quite often it doesn't which is why the best investigators are careful with their language. They distinguish between evidence, inference and speculation, even when the world around them is demanding certainty.

Other leaders could learn a great deal from that discipline. Too often we feel pressure to provide answers immediately. Teams look to us for confidence, and confidence is easily mistaken for certainty. Yet there is enormous leadership value in saying, "We don't know yet, and that's okay." Words like this create space for better questions. They encourage evidence to emerge before conclusions harden and they encourage curiosity instead of certainty. The best learning begins.

The first story is almost never the whole story

A concept we discuss regularly in is the difference between a first story and a second story.

The first story is usually obvious because it gives us an immediate explanation that appears to make sense. It is the story that develops within minutes of an event occurring, often before much evidence has been gathered. It sounds convincing because it is simple, easy to understand and usually contains someone or something that appears responsible.

"The pilot misunderstood the clearance."

"The controller made a mistake."

"They were distracted."

"They broke the rules."

Sometimes those first stories turn out to be largely correct. More often, they become only one small part of a much more complicated picture.

The second story takes considerably longer to emerge because it asks different questions. It begins by asking how the situation developed in the first place.

What information was available to the people involved?

What assumptions were they making?

What were they expecting to happen?

Were there competing priorities, unusual operating conditions or subtle pressures that shaped their decisions?

Most importantly, what barriers existed to detect and recover the error before it became a conflict, and why didn't they work as intended?

These questions aren't about removing accountability. They recognise that if we genuinely want to improve performance, understanding must come before judgement.

Imagine, for a moment, that one of the Sydney investigations eventually concludes that a pilot misunderstood an air traffic control clearance. At first glance that feels like the answer. We can all agree that misunderstanding a clearance is undesirable and move on.

Except we haven't really learned very much.

Why did the misunderstanding occur?

Was the instruction unusual?

Had the crew been expecting something different?

Was the frequency congested?

Were there multiple aircraft moving simultaneously?

Was the taxi route complex?

Did another crew member hear the same thing?

If they did, why didn't they challenge it?

If they didn't, why not?

Did the controller have opportunities to recognise the developing conflict before it reached a critical point?

What is happening here as we continue asking questions? The conversation gradually shifts away from blame and towards understanding. And valuable learning.

Errors are inevitable. Harm doesn't have to be.

One of aviation's greatest strengths is that it doesn't rely on people being perfect.

Aircraft are flown by highly trained professionals, yet the industry still assumes they will occasionally misunderstand, mishear, forget, become distracted or simply make mistakes. The same assumption applies to air traffic controllers, engineers, dispatchers and everyone else involved in the system.

As a result of this knowledge, aviation is built around layers of defence. Procedures, standard phraseology, readbacks, cross-checks, crew resource management, technology, airport design and independent monitoring all exist because the system accepts that human performance varies. The objective isn't to eliminate error. It's to prevent a single error from becoming a catastrophe.

This is why near misses so represent such awesome learning opportunities. By definition, something prevented the accident. Instead of asking only what went wrong, perhaps we should also ask what went right.

Which barrier detected the developing problem?

Which layer of defence ultimately prevented the collision?

Was that recovery something the organisation can consistently rely upon, or was it simply good fortune?

We look beyond individual actions and examine the resilience of the entire system.

Don't wait for the report to start learning

An unintended consequence of formal investigations is that organisations sometimes assume they have to wait for the final report before they can do anything useful.

I don't think that's true.

Speculation about the causes of an accident isn't helpful. At the same time, that's very different from reflecting on your own operation.

Whether the ATSB eventually attributes these Sydney events to communication, expectation bias, airport layout, workload, procedural design or something entirely different, every organisation can start asking useful questions today.

How dependent are we on one person getting it right first time?

What happens when someone misunderstands an instruction?

Where are our opportunities to detect and recover from error before it reaches the customer, the patient or the worksite?

Do people feel comfortable speaking up if something doesn't look right, even when they're uncertain?

Have we unintentionally created an environment where confidence is valued more highly than curiosity?

Conversations don't require the investigation to be complete. In fact, they're probably more valuable before it is.

The leadership challenge

Perhaps the hardest part of leadership is resisting the pressure to provide certainty when certainty doesn't yet exist. Teams naturally look to leaders for answers, particularly after significant events. Saying, "We're still gathering information," can sometimes feel unsatisfactory, especially when everyone around you appears to have already reached a conclusion. Yet one of the most important leadership behaviours is protecting the organisation from premature certainty. Once people become convinced they already know what happened, they stop looking for evidence that might prove them wrong.

That's true during formal investigations. It's equally true during everyday operational debriefs. The question isn't whether people will develop explanations. They will. The question is whether leaders create an environment where those explanations remain open to challenge as new evidence emerges.

That takes humility. It also takes discipline.

Final thoughts

The ATSB will eventually publish its findings into the Sydney Airport incidents. Those reports will almost certainly identify contributing factors, explain the sequence of events and recommend opportunities for improvement. They'll help the aviation industry become safer, just as countless investigations have done before them.

For the rest of us, however, the real opportunity begins much earlier. Every organisation experiences near misses. Most never appear on the evening news, but every one of them creates the same temptation to simplify, to judge quickly and to believe we already understand what happened.

Sometimes we're right. Quite often we're only seeing the first chapter. The challenge for leaders isn't simply learning from failure. It's learning while uncertainty still exists.

The next time an incident occurs in your organisation, resist the temptation to ask who was wrong. Instead, ask yourself something much simpler.

What don't we know yet?

It might be the most valuable question your team asks all year.

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Mike Mason and Sam Gladman help leaders and teams perform under pressure. Drawing on decades of experience in military aviation, Human Factors, accident investigation and organisational learning, they work with safety-critical organisations to improve decision-making, teamwork and leadership when conditions are uncertain. Through On Target Teaming, they combine practical tools, immersive simulations and real-world case studies to help teams perform at their best when it matters most.

If you'd like to learn more about how On Target can help your team, contact Mike and Sam at info@ontargetteaming.com.