PPRuNe Forums - View Single Post - "To err is human": differing attitudes to mistakes in EK and Turkish accidents
Old 8th May 2009, 19:02
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PJ2
 
Join Date: Mar 2003
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Silverspoonaviator;
I think your suggestion is a good one but if I might offer an observation followed by a suggestion...

What we are seeing here is the informal expression by both safety and pilot professionals who are experienced in this work and who are offering native understandings of aviation safety and how it should work. These understandings are largely (though not wholly) intuitive to the profession though likely are not part of the toolbox of many operational personnel. The notions here expressed, have been formally presented and otherwise addressed in a number of superb books listed by me and a few others earlier in the thread. If I might ensure an understanding about what's being said here, there is nothing new being said whi

If there is anything that is frustrating or confusing to those who do safety work, it is the misapprehension that safety means "wearing reflective vests on the ramp", etc, etc, etc. I agree that this thread illustrates that such work has far deeper groundings in organizational behaviours and priorities, which, contrary to another misapprehension that such processes needn't impede the primary goal of the organization - to make money for teh shareholders - but can be done reasonably and needn't attract huge expenditures. Knowing what your airline and airplanes are doing (in terms of Air Safety Reports and Flight Data as well as LOSA - Line Oriented Safety Audits - and comparing that data with what you expect and what the SOPs are, is a significant first step and while such a program is initially expensive, the awareness (and thus the safety) dividends are significant. That said, such expenditures are extremely difficult to argue for and justify to the beancounters because they think in terms of "quantities" but flight safety, by definition is about "quality", thus the latent frustration being expressed here. In other words, in response to the question, "how safe are we?" (which would be asked by somebody who didn't know what they were talking about), you cannot say "6"...but you can say, "we have a trend towards non-stabilized approaches, especially at such-and-such an airport". A suitable, diligent response would be to ask your training people and checking people what they are seeing as well and to make SOP changes then watch the data for positive responses. Clearly, being a human activity, recidivism (reverting to old habits) is an issue which requires addressing in any SOP or other procedural changes.

In my view, lomapaseo strikes a very good note in observing the concept of "best practices". One can do no more, but today in an environment of increasing "visibility" and self-regulation, one must do no less.

This kind of dialogue is unfamiliar to most operations people but shouldn't be. But education then, as lomapaseo also states, "buy-in" by operations personnel, is necessary but very difficult to come by. Most see this work as "data-deadly boring" but that is only for lack of understanding. Most safety departments are seen by the bureaucratically-ambitious, as dead-ends for their careers and frankly from what I have seen, safety departments are equivalent to either corporate purgatory or the "senate". However, again from what I am seeing, because of "visibility", "corporate governance" issues, stupendous liabilities inherent in not doing this work and the ethical issues (for me, this last is by far the largest issue), positive changes are happening. Turning a large corporation onto a slightly different course takes enormous patience, time, and effort by many, many people, comprehending these issues and talking about them instead of ignoring "the elephant in the living room", to borrow a metaphor from other interventionist dialogues which have the same goals.

My suggestion would be take what one can from an informal thread and migrate slowly towards the books and other literature which are readily available, then, perhaps formalize the issues within one's organization (if such exist!) through a series of meetings. Even if the outcomes reify that one's operation is safe, the examination is worth it. Such a dialogue must be respectful but honest/frank/open discussion. Changing world views is a very difficult, and at times, emotional challenge but as this industry is taken further towards SMS, the "privatization of flight safety" may have a positive outcome. If not and both the courage to act on data and/or the self-audit process is less than forthright, kicking tin is the alternative.

For my money, I would suggest first reading Diane Vaughan's book, (The Challenger Launch Decision) as well as Dekker's two excellent books. For a more succinct paper on Challenger, William Starbuck and Frances Milliken wrote, "Challenger; Fine-tuning the Odds Until Something Breaks" for the Journal of Management in 1988.

These processes don't hobble operations: they are a way of travelling.

"Non-stable approaches save fuel because they're fast and clean" - that illusion informs operations' thinking about what kind of approaches to tolerate. I have heard the justifications over and over, that, "the runway is long, so why are stable approaches which cost fuel, so important?" Believe it or not, I have heard management people genuinely ask this question in their desire to keep airplanes fast and clean as long as possible, despite both the data and the historical accident record.

Sometimes an expensive decision to ground an airplane from which the data has indicated a serious but undetected-by-other-processes incident has occurred. The organization must trust the process it put into place to render such decisions reasonable even though commercial priorities and pressures are high and senior managers are breathing down one's back about getting the airplane back in the air. Such "setbacks" are a matter of perception which exist in the sense of immediacy which airline life is - but a healthy safety culture takes the "long view", which is, as has been observed, a "best practice".

This whole process is like putting on a new pair of glasses. The familiar things which we have seen (or rather, because they are so familiar, we haven't seen them!), are perceived in entirely new ways, which permit newly-conceived outcomes to be positively viewed and accepted. I think that is the greatest value of this discussion.
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