Management Pt 2
Reading threads of pilots having to write letters to management justifying why they loaded extra fuel strikes a chord that the greatest impediment to further lowering of the accident rate lies in management practices external to the cockpit. One thread quipped that management are the ones who should now be attending CRM courses, and it is hard to argue against. I wonder if marketing have to justify by way of a letter to some bean counter as to why a particular flight departed with less than a profit-making load.
The latest Flight Safety Australia magazine has an article by a pilot under overbearing management pressure as to how a flight was to be conducted Mareeba to Horn Island – a GA operator, and probably a hand to mouth one as a lot are. The article gave me pause to reflect on my own experiences. Let me first say that I’m not out to cast stones or point fingers as I’ve personally made all the stuff ups its possible to make and still be a member of the human race. I merely give it for what it may be worth.
I spent a good part of my aviation career flying offshore for an operation owned and staffed by an oil company (read very deep pockets – not your fly by night GA operation). When I started the pilots were on an award and the manager was staff and as such was subject to a yearly appraisal, which then flowed on as to what his salary might be for the next twelve months. At that time I was flying a Bell 205 and although it was a VFR operation that was in name only. It was nothing to cruise at five hundred feet IMC in cloud, torrential rain, penetrate line squalls or frontal systems, snow or anything else mother nature came up with. Coming home from offshore was simplified if it was strati form type cloud, rather than sweat 35 minutes of IMC hand flying with no stab system we would climb to on top (generally 3,000) and home on the “bubble” in the cloud caused by the heat from a industrial complex located next to the heliport (Alex Henshaw approach). No approach aids were available so approaching the bubble” you let down through the muck till becoming visual (flat terrain so nothing to dodge/hit). Going outbound to a platform (we did have a coffee grinder ADF, but never worked when you needed it most) we navved by watch and compass – remarkable how good you became estimating groundspeed and drift through the chin bubble. In poor conditions it was often only because of a timely tap on the shoulder by a passenger (extra set of eyes) who appreciated the difficulties that you found your destination.
So why did we operate as we did? The aircraft were state of the art for the time in question operating in a geographical area with rapidly changing climatic conditions – blink and the weather could go from CAVOK to where you couldn’t see the water from the platform helideck (100 feet AMSL). They were also pioneering days in that the oil field was in the construction phase and early days of production. The CEO was the original 14 year old mail room boy who worked his way up and knew almost every one of a vast work force by name and thought nothing of passing the time in the crew room to get an insight into how thinks were going – as he did with all sections of the work force. In short, you were an appreciated member of the work force – to the extent that you found your award salary increased because the CEO was of the mind that because group X got a pay rise your group should get one as well.
Then came the rot. A new breed of managers moved in when the oil field was a mature business – all with an MBA in the pocket and focussed entirely on the bottom line. It’s an extreme event for senior and middle level management to venture out of the office – certainly not to talk to the hoi polloi. Every year bought forth-another announcement of an X% cut to the budget – but more expected in productivity. A budget is no longer a tool of management but an impediment to management. The pilots were made staff (willingly I might add mostly at the time) and subject to the appraisal process for salary increases. We then had a manager stand in front of the pilot group and tell us we had it too good because nobody had ever left. Nor did the company honour its undertakings with respect to how the staff system operated (surprise, surprise). Seeing the writing on the wall one of the pilots took to asking questions as to why we kept putting our a55es in a sling vis a vis compliance with the regs when the ops manual stated compliance is mandatory and we had come a long way in terms of equipment capability (autopilots, GPS, radar, no longer single pilot etc) but still operating as if we were still flogging a 205 single pilot. His appraisal for one year from the chief pilot stated “bloggs has out of perspective concerns”. Explanations to various question ranged over “you don’t need to provide for an alternate as the chance of any thing going wrong are infinitesimally small – if we followed the regs we wouldn’t do anything – you will do what you are told – you worry too much – do you want to shut the operation down”. Management seems to have lost sight of the fact that all the regs begin by saying “The PIC (is responsible, shall, will – insert word of choice).” We had fallen into the trap that this was the accepted culture (culture someone defined as its what you do when no one is looking). Was it brought about by a lack of regulatory over sight, close personal relation ship between managers and regulator? A theory I subscribe to is “The Normalisation of Deviance” (do a Google – I wont go into it here). Because the operation had never had an accident or major incident there seemed to be a belief that every thing was AOK. The good fortune had more to do with outstanding maintenance, nothing higher than 225 feet to run into (platform), experienced pilots, well equip aircraft and a healthy dose of luck in that major emergencies always took place in benign circumstances. Because the pilot was not able to push forward on the issues in house he bailed out and is of the thought that perhaps because of his approach to the authorities some ten months ago it may have given some impetus to the REPCON. As to what effect on the company, if any, is clouded by “we can’t tell you” from the authorities.
Off thread a little, but we as aviators I think are often our own worse enemies in as much as judgements we make about the errors made by fellow practitioners (the recent high speed 737 approach comes to mind – see quote of Mike Mullane below). Some of us put ourselves on rather high pedestals, and although the cockpit crew is the last line of defence for every body’s mistakes, none are supermen. Peter Garrison in “Pilot Error” wrote “Again and again, pilots are found to show little sympathy for their colleagues who are hurt or die; some simplifying explanation is immediately hit upon to reassure the others that the same fate will not be theirs”. People are people, fallible despite their best intentions, abilities, training and efforts. There can never be too much humility among those who fly. Following is a selection of quotes apropos I thinks to lessons management could well learn.
What caused both Shuttle occurrences was a confluence of deficiencies in human behaviour; normalisation of deviance, uncritical acceptance of easily verifiable erroneous assumptions, denial, willing suspension of disbelief, rejection of scientific proof, and unalterable commitment to the belief that "it can’t happen here."
Astronaut Mike Mullane commenting on the Shuttle accidents, "NASA managers, engineers and astronauts are not robots. They bring their humanity (egos, ambitions, fears, relationship issues, etc) to work just as everybody else.”
From ‘The Naked Pilot’ by David Beaty
Firstly, there should be an acknowledgment that if and when the pilot makes a mistake, his will probably be the final enabling one at the apex of a whole pyramid of errors down below. This will, in turn, take the heat off investigations – the ‘we intend to find and punish the culprit’ syndrome. Only then can the pilots come forward and admit to mistakes they made or nearly made, and the reasons why can be coolly analysed and lessons learned. [Page 285]
Professor Reason in Human Error (1990) distinguishes between active error, the effects of which are felt almost immediately, and latent error, the adverse consequences of which may lie dormant within the system for a long time. This can clearly be seen in aviation, where pilots at the sharp end make an active error, while latent error lies behind the lines within the management support system. Many of these are already there awaiting a trigger, usually supplied by the pilot. ‘There is a growing awareness within the human reliability community that attempts to discover and neutralise those latent failures will have a greater beneficial effect upon system safety than will localised efforts to minimise active errors.’
As long ago as 1980, Stanley Roscoe wrote that:
The tenacious retention of ‘pilot error’ as an accident ‘cause factor’ by governmental agencies, equipment manufacturers and airline management, and even by pilot unions indirectly, is a subtle manifestation of the apparently natural human inclination to narrow the responsibility for tragic events that receive wide public attention. If the responsibility can be isolated to the momentary defection of a single individual, the captain in command, then other members of the aviation community remain untarnished. The unions briefly acknowledge the inescapable conclusion that pilots can make errors and thereby gain a few bargaining points with management for the future.
Everyone else, including other crewmembers, remains clean. The airline accepts the inevitable financial liability for losses but escapes blame for inadequate training programs or procedural indoctrination. Equipment manufacturers avoid product liability for faulty design,. Regulatory agencies are not criticised for approving an unsafe operation, failing to invoke obviously needed precautionary restrictions, or, worse yet, contributing directly by injudicious control or unsafe clearance authorisations. Only the pilot who made the ‘error’ and his family suffer, and their suffering may be assuaged by a liberal pension in exchange for his quiet early retirement – in the event that he was fortunate enough to survive the accident
Yet it is only recently that very dubious management malpractices are being identified and their contribution to accidents given sufficient weight. For though the pilot’s actions are at the tip of the iceberg of responsibility, many other people have had a hand in it – faceless people in aircraft design and manufacture, in computer technology and software, in maintenance, in flying control, in accounts departments and in the corridors of power. But the pilot is available and identifiable. [Page 221/222]
An incident/accident is generally the result of active failures (pull the trigger) on the part of the cockpit crew, but the stage may have been set by the latent failures (load the gun and put the safety catch to ‘fire’) introduced by others (management practices, certification standards, aircraft design, software, ergonomics etc etc). Put another way, the cockpit crew is the last line of defence for every ones mistakes. As good as you may think yourself, none of us are all knowing.
Capt. Fenwick of ALPA has cautioned. "Pilots will be judged against the perfect pilot flying the perfect airplane on the perfect flight. We all know that no such thing exists.”
PS Thanks for putting up with the rant if you got this far.
PPS One word described our company safety program under the new management style – punitive.