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View Full Version : “They wanted systems that could take responsibility instead of people.”


alf5071h
4th Dec 2012, 13:20
“They wanted systems that could take responsibility instead of people” (ww.nytimes.com/2012/11/15/world/europe/bbc-failures-show-limits-of-guidelines.html?smid=li-share&goback=.gde_1191767_member_171675115&_r=1&) is an excerpt from The New York Times on recent events at the BBC, referring to a style of management.

Could similar excessive use of rules and procedures lead to a failure in flight safety?

“One compared what happened to a plane spiraling out of control in which the pilot, rather than pulling on the controls, reaches for an instruction manual and begins to check off steps. … there is no choice but to reach for the manual.”

Could the underlying principles of such an organisational ‘failure’ apply to areas of aviation; if so what might be learnt?
Are there early warning signs; what could / should be done?

Further excerpts for thought:

“… established elaborate bureaucratic procedures … put an increasing emphasis on “compliance.”

“… it appears that people overseeing the program were too cautious, so that top managers were left unaware …; managers may have relied too much on rigid procedures at the expense of basic … principles.”

“… because it had been “lawyered” and “complied,” meaning it had passed the requisite legal and compliance tests, and been “referred up” the chain of responsibility, [I] was considered sound — even though no one, apparently, had asked standard questions like whether [I] was credible.”

“… people along the chain were more concerned with checking the right boxes than with asking the right questions.”

Stratocaster
5th Dec 2012, 12:59
Can't say much about the intent/objectives at the BBC, but suggest reading James Reason (again): "Writing another procedure" page 49 of his book "Managing the risks of the organizational accidents" published 15 years ago.

Armchairflyer
5th Dec 2012, 20:06
Reason's "Managing the risks of the organizational accidents" is indeed one of the most citable sources I find. Another book that discusses how procedures that are too rigid and/or removed from "sharp end reality" often fail to achieve their goal but rather lead to a "normalization of deviance" is Sidney Dekker's "Drift into failure" (p. 103ff.). Still another study that extensively deals with the gap between work-as-planned and work-as-real and its consequences in an airline flying context is "The Multitasking Myth" by Loukia Loukopoulos, Robert Key Dismukes, and Immanuel Barshi.

Capot
6th Dec 2012, 12:14
The quotes in the OP's post sum up everything that's wrong with the approach to Safety Management that is being promulgated by the UK CAA, to name but one of many culprits.

They have a sincere and touching faith that so long as an Accountable Manager has signed a "Safety Policy statement" all will be well. They even provide a template for the words (and many Surveyors insist that it must be used; original thinking about what it should say is not acceptable) so that the Accountable Manager is spared the time-consuming task of working out what his policy should be.

More seriously, the triumph of auditing process rather than outcome is complete; the regulatory auditor must complete a (short) course on how to audit, but technical knowledge, considerable experience and expertise in the operation being audited, eg aircraft maintenance, is not required.

safetypee
6th Dec 2012, 17:24
The similarities in aviation are in people’s attitudes, and with management and organisational culture; both biased by modern society. The world is becoming a place of instant/superficial answers; apps, Google, ECAM, QRH. Blame and Train cultures still dominate aviation safety.
The increasing drive for efficiency and the ever present threat of litigation (personal retribution or organisation prosecution) results in a by-the-book attitude.
Training mimics this; - there’s no need to look deeper into a subject due to higher reliability and that there will be a procedure, thus when faced with a novel or untrained-for situation people struggle for answers, often reverting to the nearest procedure, right or wrong. The human goal is influenced by avoiding blame.

Pilots are not always taught, nor have sufficient opportunity to gain the experience necessary to evaluate novel situations, create, and choose appropriate solutions.
There may even be an expectation that every situation will have a drill (Checklist/QRH), or that company procedures will provide guidance, except that many standard procedures (SOP) are increasingly situation specific and fail to provide general guidance.

The industry appears to be operating closer to previously established safety boundaries. A good level of safety can be maintained providing pilots are not frequently exposed to novel or untrained situations and, if they are, that procedural guidance is sufficient. This implies the need for a balance between training, operating task, and reliability; the industry has to aid pilots meet demands of routine situations and protect them from the extreme situations.

While the industry maintains its good safety level then the balance is sufficient, but we must take heed of warning signs, not necessarily the fatal accident rate, but the hull losses (cost) and incidents.
See EASA Annual Safety Review (www.skybrary.aero/bookshelf/books/1860.pdf); do not overly focus on LOC and CFIT (page 22), but also consider systems failures, ramp issues, runway excursion, and abnormal runway contact, and ATM ground collision issues. Apart from aircraft systems, there are few procedures for these situations.
The industry must recognise its dependency on people.