Chasing the Small Stuff: How Micro-Deficiencies Can Lead to Major Failures
In aviation, we train to spot the big problems: runway incursions, bird strikes, mechanical malfunctions. But history has proven that it's often the small things—the overlooked, the mundane, the "not-a-big-deal" items—that create the biggest consequences. These are micro-deficiencies, and left unchecked, they can unravel even the most robust safety system.
The Concorde: A Tragedy Sparked by a Strip of Metal
On July 25, 2000, Air France Flight 4590 crashed shortly after takeoff, killing all 109 people on board and four on the ground. The cause was determined to be a titanium alloy strip that had fallen from a Continental Airlines DC-10 that had departed minutes earlier. That strip, just 17 inches long, punctured a Concorde tire during takeoff. The ruptured tire sent debris into the fuel tank, causing a catastrophic fire.
This is the very definition of a micro-deficiency with macro consequences. A missed FOD check, an unnoticed part on a runway, a failure to follow up on proper fastener inspections—each of these things can snowball.
Other Real-World Micro-Deficiencies That Escalated
1. Tenerife Airport Disaster (1977): Miscommunication and fog were the headline factors, but a contributing micro-deficiency was the lack of ground radar, which meant air traffic control had no visibility of aircraft positions during the crucial moments.
2. Northwest Airlines Flight 255 - Detroit, Michigan (1987): The aircraft crashed after takeoff due to the flight crew's failure to use the taxi checklist which included deployment of flaps and slats. The warning system that should have alerted the crew did not activate—a small electrical failure in a system many took for granted.
3. Asiana Airlines Flight 214 - San Francisco, California (2013): The Asiana Airlines flight struck a seawall on landing. While pilot error was primary, contributing deficiencies included the deactivation of key autothrottle features and insufficient clarity in SOPs around manual flying practices at low altitudes.
Why Micro-Deficiencies Matter
Micro-deficiencies are like hairline cracks in a dam. At first, they're invisible or easily dismissed. Over time, they multiply or align in just the wrong way—and that’s when systems fail. The role of a proactive safety culture is to detect and address these gaps before they line up into a catastrophe.
Unchecked micro-deficiencies:
Corrode trust in processes
Undermine safety culture
Create false confidence
Reduce operational resilience
Strategies for Identifying and Eliminating Micro-Deficiencies
To chase the small stuff, you need to build a system that does more than just hope someone notices. Here are actionable strategies:
1. Review Inspection Reports
Randomly audit and verify inspection reports.
Look for repeated notes or vague entries (e.g. "good," "checked") that mask lack of detail.
Follow up on deferred maintenance or recurring issues.
2. Vehicle Circle Check Compliance
Verify that vehicle circle checks are happening as scheduled and as per procedure.
Spot-check logs and ask operators to demonstrate the process.
Reinforce the value of proper documentation. Better yet, have a system that ensures documentation is done correctly.
3. Scheduled Preventive Tasks
Ensure preventive maintenance tasks like FOD sweeps, lighting checks, and equipment servicing are scheduled.
Use a management system tool like Wombat to schedule, assign, and track these tasks.
Automate reminders and flag overdue items.
4. Standard Operating Procedures (SOPs)
Confirm all safety-critical tasks have clear, current SOPs.
Conduct work observations: are people doing the task the way it’s written?
If not, find out why. Update the SOP or retrain accordingly.
5. Empower Staff to Report Small Issues
Foster a culture where "small stuff" is worth reporting.
Reward attention to detail.
Include micro-deficiency identification in toolbox talks and safety meetings.
Close the Loop
The final piece is closing the loop. Having SOPs, inspections, and checklists is not enough. You need to:
Confirm the process is happening.
Evaluate its effectiveness.
Make changes when it's not working.
That’s what continuous improvement looks like. That’s what proactive safety management is. And that’s how you prevent the small stuff from becoming your headline.
Need help implementing systems that keep small issues from turning into big ones? Acclivix and Wombat Safety Software work together to ensure you're not only spotting micro-deficiencies, but addressing them before they grow.