"To err is human": differing attitudes to mistakes in EK and Turkish accidents
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How refreshing to see such a fascinating debate on such an important subject. Although I cannot add anything of particular import to the proceedings, I would like to join the debate with part of the conclusion of a paper that I recently wrote, entitled, 'Where are we going with the Accident Rate?'. Although I will be guilty of repeating some of the points already made I consider it a privilege to be part of this discussion.
Thank you,
GW
"6. Conclusion
The above no way implies criticism of the entire industry; indeed, most pilots and managers perform to admirable standards, often under enormous commercial and operational pressures. However, as an industry we have no right to go on killing people and losing aircraft at the present rate, especially when most losses are totally avoidable. If I had to identify one area that causes me most concern it would be over-reliance on automation and reduction of manual handling skills. Engaging the autopilot immediately after take-off and disengaging it immediately prior to landing may result in an efficient, fuel-saving flight, but insistence by management that automation is used exclusively leads to reduction of handling skills and possible confusion when an unfamiliar situation develops. The current increase in loss of control in flight incidents / accidents may well be at least partly attributable to this. Although the current move to improve 'Upset Recovery' training is all well and good we should also be ensuring that crews do not get into the situation in the first place. Knowledge of the handling characteristics of the aircraft in all stages of flight, combined with good handling skills, will help alleviate the problem.
In an ideal world, every flight would be routine, the weather perfect. Engine failures would occur precisely at V1 and all abnormal and emergency situations would occur in the cruise, without any distraction and with plenty of time to run appropriate checklists. However, as we know, this is rarely the case. Whereas some pilots are fortunate, with their incidents occurring under ideal conditions and no decisions required other than to land the aircraft immediately, others face situations that test their technical knowledge and handling skills to the limit. Unfortunately, and all too often, the latter situations do not get the publicity they deserve, which is a lost public relations opportunity apart from anything else.
As an industry we need to train thinking pilots and all too often we are not doing that. Instead we place our faith in technology and rather than developing human skills and knowledge to match the improvements in technology, we often do the opposite. New cockpit designs and procedures place great emphasis on heads-down activity, drawing attention away from what is happening outside the cockpit with a commensurate decrease in situational awareness. Recruitment and training bear special mention. In times of rapid growth in the industry demand often exceeds supply and people end up in the cockpit with less than desirable experience and, in some cases, aptitude for the job. More needs to be done to weed out those who do not have the personal attributes to perform consistently as required, in all situations and always to an acceptable standard. Fear of legal consequences has led to training and check reports being marked 'satisfactory' or 'unsatisfactory'. I would suggest that there is nothing less satisfactory than those two comments. Unless there is a comprehensive paper trail that can be followed in the event of an accident, how can we ever validate our recruitment and training systems? Failing to do this is dishonesty of the highest order.
Pilots and managers share responsibility for the standards in our industry. When things go wrong it is far too easy to blame the regulators, manufacturers and others who have an influence. At the end of the day, we know what is right and what is not, what we should and should not do. We need to make more effort to come together to address those issues that we know are in need of attention."
Thank you,
GW
"6. Conclusion
The above no way implies criticism of the entire industry; indeed, most pilots and managers perform to admirable standards, often under enormous commercial and operational pressures. However, as an industry we have no right to go on killing people and losing aircraft at the present rate, especially when most losses are totally avoidable. If I had to identify one area that causes me most concern it would be over-reliance on automation and reduction of manual handling skills. Engaging the autopilot immediately after take-off and disengaging it immediately prior to landing may result in an efficient, fuel-saving flight, but insistence by management that automation is used exclusively leads to reduction of handling skills and possible confusion when an unfamiliar situation develops. The current increase in loss of control in flight incidents / accidents may well be at least partly attributable to this. Although the current move to improve 'Upset Recovery' training is all well and good we should also be ensuring that crews do not get into the situation in the first place. Knowledge of the handling characteristics of the aircraft in all stages of flight, combined with good handling skills, will help alleviate the problem.
In an ideal world, every flight would be routine, the weather perfect. Engine failures would occur precisely at V1 and all abnormal and emergency situations would occur in the cruise, without any distraction and with plenty of time to run appropriate checklists. However, as we know, this is rarely the case. Whereas some pilots are fortunate, with their incidents occurring under ideal conditions and no decisions required other than to land the aircraft immediately, others face situations that test their technical knowledge and handling skills to the limit. Unfortunately, and all too often, the latter situations do not get the publicity they deserve, which is a lost public relations opportunity apart from anything else.
As an industry we need to train thinking pilots and all too often we are not doing that. Instead we place our faith in technology and rather than developing human skills and knowledge to match the improvements in technology, we often do the opposite. New cockpit designs and procedures place great emphasis on heads-down activity, drawing attention away from what is happening outside the cockpit with a commensurate decrease in situational awareness. Recruitment and training bear special mention. In times of rapid growth in the industry demand often exceeds supply and people end up in the cockpit with less than desirable experience and, in some cases, aptitude for the job. More needs to be done to weed out those who do not have the personal attributes to perform consistently as required, in all situations and always to an acceptable standard. Fear of legal consequences has led to training and check reports being marked 'satisfactory' or 'unsatisfactory'. I would suggest that there is nothing less satisfactory than those two comments. Unless there is a comprehensive paper trail that can be followed in the event of an accident, how can we ever validate our recruitment and training systems? Failing to do this is dishonesty of the highest order.
Pilots and managers share responsibility for the standards in our industry. When things go wrong it is far too easy to blame the regulators, manufacturers and others who have an influence. At the end of the day, we know what is right and what is not, what we should and should not do. We need to make more effort to come together to address those issues that we know are in need of attention."
For me GW, very well stated indeed - it may be the same elephant in the living room but stating it as many ways as possible is needed. Well done, in my view. I think Canada in particular, needs to hearken to the message - the FAA in the U.S. has already been chastened by events under SMS. We can only avoid the outcomes of the privatization of safety for so long.
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When you have both poor maintenance and poor airmanship in an airline, it’s no use to blablabla about human factors after an accident. You need first to question about mediocrity and safety culture
When you have both poor maintenance and poor airmanship in an airline, it’s no use to blablabla about human factors after an accident. You need first to question about mediocrity and safety culture
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I found this thread very interesting.
In my opinion there is something missing on this thread.
Great contributions form the likes of P2J, lomapaseo and many others...
However I found still puzzling the understanding of "lack of training" and "poor airmanship in the airline".
I questioned in the past how a pilot will deal if he/she feels that him/her was in need of extra training. I did not get a clear cut reply!
I am a SLF therefore my opinion/feeling are definitely questionable, but let me say that the issue of lack of training sounds more like as a good excuse to shift the blame. Same goes with the "culture issue", another way to find something to blame for systemic failures.
Let me explain, I assume that all the pilots are highly trained professionals, which are "immune" (cannot find a better word) from incompetence and "culture issues". I also assume that all the pilots are 100% dedicated to their job and would not compromise on any safety related issue.
If my assumptions are correct, why to blame the lack of training? If a professional feels that his/her training is not the best should voice his/her concern about it...
Furthermore highly trained professional should not be influenced by "culture issues". He/her should be able to overcame such issues without a blink of eyes.
Am I really out of bounds?
Are we witnessing a degrading of the level of professionalism of your category?
I might sound provocative, I regret that, but I feel that it should be a topic of discussion. We (you actually) cannot dismiss easily the type 3 errors (Turkish), saying that those pilots where incompetent. IMHO the first question should be "why they were incompetent?"
Just my 2c.
In my opinion there is something missing on this thread.
Great contributions form the likes of P2J, lomapaseo and many others...
However I found still puzzling the understanding of "lack of training" and "poor airmanship in the airline".
I questioned in the past how a pilot will deal if he/she feels that him/her was in need of extra training. I did not get a clear cut reply!
I am a SLF therefore my opinion/feeling are definitely questionable, but let me say that the issue of lack of training sounds more like as a good excuse to shift the blame. Same goes with the "culture issue", another way to find something to blame for systemic failures.
Let me explain, I assume that all the pilots are highly trained professionals, which are "immune" (cannot find a better word) from incompetence and "culture issues". I also assume that all the pilots are 100% dedicated to their job and would not compromise on any safety related issue.
If my assumptions are correct, why to blame the lack of training? If a professional feels that his/her training is not the best should voice his/her concern about it...
Furthermore highly trained professional should not be influenced by "culture issues". He/her should be able to overcame such issues without a blink of eyes.
Am I really out of bounds?
Are we witnessing a degrading of the level of professionalism of your category?
I might sound provocative, I regret that, but I feel that it should be a topic of discussion. We (you actually) cannot dismiss easily the type 3 errors (Turkish), saying that those pilots where incompetent. IMHO the first question should be "why they were incompetent?"
Just my 2c.
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Thanks PJ .........
Thanks PJ, I am encouraged by all the comments made so far. Clearly, we are all thinking along the same lines. However, the piecemeal approach that we are taking merely dilutes the efforts. Well-intentioned people work hard to improve things - and I include managers as well as pilots - but often with differing interpretations of what is the most effective way to proceed. The mandating of SMS (for instance) is all well and good but unless there are clear guidelines of exactly what is required there could be as many different systems as there are operators.
As someone who has seen the problems from both the line pilot and management sides, the solution seems obvious. Both sides have to work closely together. Each has to set aside the mistrust that predominates in many operations, and I include here corporate (business) operators as well as the airlines. There are glimmers of hope: pilot / management relations are excellent with some operators, but, sadly, not in all.
Clearly, there isn't a shortage of good ideas. We have seen many offered here in the last few days. How we collate those in a useable form and get all stakeholders to buy in is the challenge.
Regards,
GW
As someone who has seen the problems from both the line pilot and management sides, the solution seems obvious. Both sides have to work closely together. Each has to set aside the mistrust that predominates in many operations, and I include here corporate (business) operators as well as the airlines. There are glimmers of hope: pilot / management relations are excellent with some operators, but, sadly, not in all.
Clearly, there isn't a shortage of good ideas. We have seen many offered here in the last few days. How we collate those in a useable form and get all stakeholders to buy in is the challenge.
Regards,
GW
FrequentSLF;
Your questions and observations are valid in the sense that they are legitimate and thoughtful questions to ask.
First, your observation regarding the very high level of professionalism, dedication and "address", (a term that intends to convey the notion that on is "aggressively, thoughtfully and caringly professional) by 99% of aircrews is correct in a number of senses, the main one being, aviation kills those who are habitually inattentive or careless.
I think it is safe to say that there is not one person who is now flying commercially, professionally who does not know the instant rush of adrenaline and all the other sudden physiological responses which follow a serious incident in which one almost lost one's life and almost cost the lives of one's passenger(s); one never forgets the sensation - it is never "familiar". It is equally safe to say that 99% of all pilots will know at least one friend or aquaintance if not a few who were killed in an aircraft accident.
These are viscerally effective teachers, the lessons from which are not forgotten.
It is a pity that neither the bean-counting crowd nor the CEOs, Presidents or other executives of aviation companies experience such primordial levels of physiological response; they might be a bit more careful and attentive themselves to the business they're in and "fly the virtual airplane" more mindfully. I don't mean this unkindly or in a "bashing management" way - I think it is crucial for executive level managements to know how safety works and that it certainly isn't admonishng someone to "not run with a knife", or to "be careful out there", etc.
This in hand, we all know that comfort and complacency are psychological states of mind to which humans are susceptible and which, when permitted, have sociological and organizational expressions, captured under many new awarenesses the most recent of which is called "the normalization of deviance".
It is not the easiest thing to "be aware of what one doesn't know", at least until one meets circumstances which challenge one's "address" significantly enough to momentarily set one back on one's heels. That is a human trait as well. That is one of the chief projects of safety work - to highlight heretofor "invisible" factors, bringing into awareness those issues and circumstances which may harm one, or one's organization.
In a healthy safety culture, if one feels the need for training, one asks for it and one is granted the opportunity.
The caveats are interesting however. One asks because one is "lacking" - and for a pilot to admit same or to be shown as lacking through failure, especially in a culture where macho he-men "make no mistakes", (or fire those who do). Such cultures exist, (as we have seen here), and one does not always obtain the necessary and appropriate response.
In airlines which have a functioning FOQA Program with an associated safety culture that takes such a program seriously, an agreement between the airline and the pilots' association will inevitably be in place which permits the addressing of competency/training issues as may be showing up in the data.
This doesn't mean that management is using data to "go after" a pilot. The arrangement is, the pilots' association accepts the responsibility of approaching an individual, discussing the what and why and, through the FOQA Agreement, scheduling training as needed. The entire process is "below management's radar" but they are aware due diligence is served. These kinds of responses are extremely rare; in circumstances which may call for some comment, it is a "fine-tuning" response usually from simulator or checkride sessions and the individual almost always voluntarily addresses the situation.
I have, with others, built these processes, seen them in play and know all of this works and works extremely well, but the company must obviously be onside and trust the process.
Usually, long before anything "semi-formal" arises, one's colleagues with whom one shares a pretty tiny environment, may make respectful but necessary observations which go to the same point - competency and training. Increasingly, this is done without fear of reprisal, hostility or pouting in the corner... That's a small part of what CRM is. One would hope that at some point the medical profession will arrive at this same level of mini-intervention where one's professionalism and integrity remains intact but a caring observation from a colleague can still remind one that something may need attention.
Enlightened organizations which know that employees are tremendous assets and not mere millstones around profit's neck will have programs which can formally or informally intervene when something is coming off the rails. Financial issues, family issues, health issues, addiction issues and so on affect everyone; discipline or dismissal is almost always never an appropriate response. Peer-to-peer programs, Employee Care programs and so on provide necessary responses long before the collective agreement clauses are anticipated or used.
I know of no major carriers who enjoy long-term success in this squirrely industry which do not have all these approaches to human factors in place to some degree or other.
We should be under no illusions either; These programs aren't about social "wellness" just for the sake of it; corporations are clearly not in the social welfare business as we well know - these programs are about employee productivity and keeping valuable, highly-trained resources at work and functioning towards the company's only goal - financial success.
To your last point regarding, "are we experiencing a degrading of professionalism...?", - In my view and as I have expressed a number of times here, yes, we are.
Even as though personal standards and integrity in pilots is in the end a survival tool, such endeavours and standards must be fostered and supported within the organization. It is a complex inter-relation which cannot rely solely on "personal standards" to retain high safety levels. The best example I can think of are the two Shuttle accidents. Can one think of a more highly-trained, dedicated and professional crew than those of Challenger and Columbia. But it is clearly demonstrated in the hundreds of studies, papers and books on these two accidents, that they were purely "organizational" in nature; there was absolutely nothing either crew could have done either before launch or during flight that could have saved the mission.
I realize that these are outlying examples and that airline work is much farther away from such operational boundaries; but the principles are the same. If we turn to the pilots for the reason an accident occurred, we will not know the whole story and so it will repeat itself again, either within the same organization, or, because sharing information is still very much in it's infancy (in terms of trust as well as airline interest), within other airlines.
FSLF, hope this is useful - this is the stuff of large books and late nights, y'know!
Your questions and observations are valid in the sense that they are legitimate and thoughtful questions to ask.
First, your observation regarding the very high level of professionalism, dedication and "address", (a term that intends to convey the notion that on is "aggressively, thoughtfully and caringly professional) by 99% of aircrews is correct in a number of senses, the main one being, aviation kills those who are habitually inattentive or careless.
I think it is safe to say that there is not one person who is now flying commercially, professionally who does not know the instant rush of adrenaline and all the other sudden physiological responses which follow a serious incident in which one almost lost one's life and almost cost the lives of one's passenger(s); one never forgets the sensation - it is never "familiar". It is equally safe to say that 99% of all pilots will know at least one friend or aquaintance if not a few who were killed in an aircraft accident.
These are viscerally effective teachers, the lessons from which are not forgotten.
It is a pity that neither the bean-counting crowd nor the CEOs, Presidents or other executives of aviation companies experience such primordial levels of physiological response; they might be a bit more careful and attentive themselves to the business they're in and "fly the virtual airplane" more mindfully. I don't mean this unkindly or in a "bashing management" way - I think it is crucial for executive level managements to know how safety works and that it certainly isn't admonishng someone to "not run with a knife", or to "be careful out there", etc.
This in hand, we all know that comfort and complacency are psychological states of mind to which humans are susceptible and which, when permitted, have sociological and organizational expressions, captured under many new awarenesses the most recent of which is called "the normalization of deviance".
It is not the easiest thing to "be aware of what one doesn't know", at least until one meets circumstances which challenge one's "address" significantly enough to momentarily set one back on one's heels. That is a human trait as well. That is one of the chief projects of safety work - to highlight heretofor "invisible" factors, bringing into awareness those issues and circumstances which may harm one, or one's organization.
In a healthy safety culture, if one feels the need for training, one asks for it and one is granted the opportunity.
The caveats are interesting however. One asks because one is "lacking" - and for a pilot to admit same or to be shown as lacking through failure, especially in a culture where macho he-men "make no mistakes", (or fire those who do). Such cultures exist, (as we have seen here), and one does not always obtain the necessary and appropriate response.
In airlines which have a functioning FOQA Program with an associated safety culture that takes such a program seriously, an agreement between the airline and the pilots' association will inevitably be in place which permits the addressing of competency/training issues as may be showing up in the data.
This doesn't mean that management is using data to "go after" a pilot. The arrangement is, the pilots' association accepts the responsibility of approaching an individual, discussing the what and why and, through the FOQA Agreement, scheduling training as needed. The entire process is "below management's radar" but they are aware due diligence is served. These kinds of responses are extremely rare; in circumstances which may call for some comment, it is a "fine-tuning" response usually from simulator or checkride sessions and the individual almost always voluntarily addresses the situation.
I have, with others, built these processes, seen them in play and know all of this works and works extremely well, but the company must obviously be onside and trust the process.
Usually, long before anything "semi-formal" arises, one's colleagues with whom one shares a pretty tiny environment, may make respectful but necessary observations which go to the same point - competency and training. Increasingly, this is done without fear of reprisal, hostility or pouting in the corner... That's a small part of what CRM is. One would hope that at some point the medical profession will arrive at this same level of mini-intervention where one's professionalism and integrity remains intact but a caring observation from a colleague can still remind one that something may need attention.
Enlightened organizations which know that employees are tremendous assets and not mere millstones around profit's neck will have programs which can formally or informally intervene when something is coming off the rails. Financial issues, family issues, health issues, addiction issues and so on affect everyone; discipline or dismissal is almost always never an appropriate response. Peer-to-peer programs, Employee Care programs and so on provide necessary responses long before the collective agreement clauses are anticipated or used.
I know of no major carriers who enjoy long-term success in this squirrely industry which do not have all these approaches to human factors in place to some degree or other.
We should be under no illusions either; These programs aren't about social "wellness" just for the sake of it; corporations are clearly not in the social welfare business as we well know - these programs are about employee productivity and keeping valuable, highly-trained resources at work and functioning towards the company's only goal - financial success.
To your last point regarding, "are we experiencing a degrading of professionalism...?", - In my view and as I have expressed a number of times here, yes, we are.
Even as though personal standards and integrity in pilots is in the end a survival tool, such endeavours and standards must be fostered and supported within the organization. It is a complex inter-relation which cannot rely solely on "personal standards" to retain high safety levels. The best example I can think of are the two Shuttle accidents. Can one think of a more highly-trained, dedicated and professional crew than those of Challenger and Columbia. But it is clearly demonstrated in the hundreds of studies, papers and books on these two accidents, that they were purely "organizational" in nature; there was absolutely nothing either crew could have done either before launch or during flight that could have saved the mission.
I realize that these are outlying examples and that airline work is much farther away from such operational boundaries; but the principles are the same. If we turn to the pilots for the reason an accident occurred, we will not know the whole story and so it will repeat itself again, either within the same organization, or, because sharing information is still very much in it's infancy (in terms of trust as well as airline interest), within other airlines.
FSLF, hope this is useful - this is the stuff of large books and late nights, y'know!
I'm just probing a little more here to better adjust my own points of view.
I'm always bothered by throwing a problem over the fence with such throwaway words as:
they screwed up... end of story
The bean counters are in the way
management doesn't care
it's in their culture
etc. etc.
OK maybe those words are a little over the top, but they do serve as an introduction to what I sense
In my own interactions with the safety professionals within our industry I do see dedication and an unwillingness to sweep things under the rug. Furthermore I do not hear any sounds of the crass statements that I made above in my introduction.
So why am I hearing it here on this board?
I do recognize that the great majority of us don't work directly in a flight safety office, but for personal knowledge of those that do (third hand or better) just how restricted are your hands tied from identifying shortfalls and following up that they are addressed?
Am I to understand that this is a ad-hoc issue and even driven by culture? or do the great majority attend to these issues in an openly funded process free from interference from bean counters and management politics?
I'm always bothered by throwing a problem over the fence with such throwaway words as:
they screwed up... end of story
The bean counters are in the way
management doesn't care
it's in their culture
etc. etc.
OK maybe those words are a little over the top, but they do serve as an introduction to what I sense
In my own interactions with the safety professionals within our industry I do see dedication and an unwillingness to sweep things under the rug. Furthermore I do not hear any sounds of the crass statements that I made above in my introduction.
So why am I hearing it here on this board?
I do recognize that the great majority of us don't work directly in a flight safety office, but for personal knowledge of those that do (third hand or better) just how restricted are your hands tied from identifying shortfalls and following up that they are addressed?
Am I to understand that this is a ad-hoc issue and even driven by culture? or do the great majority attend to these issues in an openly funded process free from interference from bean counters and management politics?
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#1 RA wasn't working properly. It did not cause the crash, the pilots who are normally monitoring instruments caused the crash by not monitoring. I don't think Boeing has much to do with this crash. You can not make an aircraft so safe that the most incompetent crew in the world can fly it with no problems. Airbus may try to make pilots unable to screw up but I hope Boeing doesn't. Having final control of the aircraft and no computer overiding me has been wonderful in my career. I love Boeing products that let you overide anything that doesn't do what you want. I know this was a Boeing but nobody was flying it.
lomapaseo;
In my 20-year experience as a safety specialist I never experienced tied hands, fear of reprisals or job security or restrictions in identifying shortcomings, even when speaking directly to senior executives. Funding, while strategically parsimonious to a fault, was still there even under difficult economic circumstances.
Your question assumes however, perhaps without intending it, that if these aren't issues then everything will proceed normally because who could be in possession of the data and then not use it? It seems so obvious as to be not worth considering. But in my experience it must be considered.
If a carrier collects FOQA safety data but does little or nothing with it or simply ignores or dismisses it as "wrong" (when inconvenient) or otherwise explains serious occurences away, is one still "doing safety"? I submit that such box-ticking is not doing safety at all but is merely satisfying SMS requirements, or rather the illusion, "to have a program in place." That's just not how SMS is supposed to be done, at least in my understanding - you're supposed to collect data, review it regularly and, where indicated, change, and not take a few years to do so when the data indicates a consistent high-risk trend in aspects of the operation.
Obviously this isn't the place for a detailed discussion but I can assure you without hesitation and with plenty of examples that the impeding factors and "characterizations" which you describe above have been, in my 2 decade experience as a safety specialist, unmistakable and significant. I don't use the terms I do lightly.
But you make a valuable point nevertheless. "Parsimony" or aggressive cost-control do not, in and of themselves, "cause incidents/accidents". I think that is an important point to understand and I think this is your point: We cannot "blame" the bean-counters for "not installing this-or-that, or funding this-or-that" in and of itself. Some very fine operations continue unaffected with thin budgets. It is when an organization over-reaches it's funded risk mitigation strategies and, further, isn't aware that it has done so, that risk increases significantly.
To support this point even moreso, most of the serious incidents and high-risk trends I/we became aware of and communicated (vigourously and often) to the appropriate personnel, were not high-cost items to fix. I think this is the case with the vast majority of causal pathways (why-because) - shortage of money was not a factor; awareness and the corporate will to act, however, were.
I think the term "beancounter" is used pejoratively by many including me, to inform others of their frustrations with the larger processes of change or rather the thwarting of change when/where indicated from a safety program point of view. I think the duty day and crew fatigue issue is a exact case in point. Crew costs are always right at the coal-face just as fuel costs are. Where our professional differences lie is in the tremendous lobbying efforts by those who we see as interested only in pairing down costs without sufficient or educated justifications, to enhance "the bottom line".
That is the "story" for us. How it is viewed from our beancounters' side has, to my knowledge, never been provided, not at least to us. They simply ignore what we have to say about crew fatigue and the causes of accidents and carry on lobbying and complaining about the cost of fourth pilots or pilots doing safety work with reduced flying schedules. I am certain that pilots are seen as whiners, complainers and prima-donnas by those who have never been along on a trip and seen what is done to keep our, and their, operation going. 'Twas ever thus.
I do recognize that the great majority of us don't work directly in a flight safety office, but for personal knowledge of those that do (third hand or better) just how restricted are your hands tied from identifying shortfalls and following up that they are addressed?
Am I to understand that this is a ad-hoc issue and even driven by culture? or do the great majority attend to these issues in an openly funded process free from interference from bean counters and management politics?
Am I to understand that this is a ad-hoc issue and even driven by culture? or do the great majority attend to these issues in an openly funded process free from interference from bean counters and management politics?
Your question assumes however, perhaps without intending it, that if these aren't issues then everything will proceed normally because who could be in possession of the data and then not use it? It seems so obvious as to be not worth considering. But in my experience it must be considered.
If a carrier collects FOQA safety data but does little or nothing with it or simply ignores or dismisses it as "wrong" (when inconvenient) or otherwise explains serious occurences away, is one still "doing safety"? I submit that such box-ticking is not doing safety at all but is merely satisfying SMS requirements, or rather the illusion, "to have a program in place." That's just not how SMS is supposed to be done, at least in my understanding - you're supposed to collect data, review it regularly and, where indicated, change, and not take a few years to do so when the data indicates a consistent high-risk trend in aspects of the operation.
Obviously this isn't the place for a detailed discussion but I can assure you without hesitation and with plenty of examples that the impeding factors and "characterizations" which you describe above have been, in my 2 decade experience as a safety specialist, unmistakable and significant. I don't use the terms I do lightly.
But you make a valuable point nevertheless. "Parsimony" or aggressive cost-control do not, in and of themselves, "cause incidents/accidents". I think that is an important point to understand and I think this is your point: We cannot "blame" the bean-counters for "not installing this-or-that, or funding this-or-that" in and of itself. Some very fine operations continue unaffected with thin budgets. It is when an organization over-reaches it's funded risk mitigation strategies and, further, isn't aware that it has done so, that risk increases significantly.
To support this point even moreso, most of the serious incidents and high-risk trends I/we became aware of and communicated (vigourously and often) to the appropriate personnel, were not high-cost items to fix. I think this is the case with the vast majority of causal pathways (why-because) - shortage of money was not a factor; awareness and the corporate will to act, however, were.
I think the term "beancounter" is used pejoratively by many including me, to inform others of their frustrations with the larger processes of change or rather the thwarting of change when/where indicated from a safety program point of view. I think the duty day and crew fatigue issue is a exact case in point. Crew costs are always right at the coal-face just as fuel costs are. Where our professional differences lie is in the tremendous lobbying efforts by those who we see as interested only in pairing down costs without sufficient or educated justifications, to enhance "the bottom line".
That is the "story" for us. How it is viewed from our beancounters' side has, to my knowledge, never been provided, not at least to us. They simply ignore what we have to say about crew fatigue and the causes of accidents and carry on lobbying and complaining about the cost of fourth pilots or pilots doing safety work with reduced flying schedules. I am certain that pilots are seen as whiners, complainers and prima-donnas by those who have never been along on a trip and seen what is done to keep our, and their, operation going. 'Twas ever thus.
Last edited by PJ2; 8th May 2009 at 00:50.
PJ2
Thanks for your as always thoughtful reply. Let's see what others might also contribute.
You have pointed out a couple of points which I take as:
Some safety folks don't recognize or properly use the data available to them. That's a big problem if it turns out to be pervasive.
The pilot fatigue problem is not being captured in the safety data and as such continues as an unabated and possibly increasing risk.
I'll probably have more to say about both of these points if they turn out to be well supported across the other posters
Thanks for your as always thoughtful reply. Let's see what others might also contribute.
You have pointed out a couple of points which I take as:
Some safety folks don't recognize or properly use the data available to them. That's a big problem if it turns out to be pervasive.
The pilot fatigue problem is not being captured in the safety data and as such continues as an unabated and possibly increasing risk.
I'll probably have more to say about both of these points if they turn out to be well supported across the other posters
lomapaseo;
No, that's not what I meant - it is when the safety people do their due diligence, report what is being seen in the data, and what is reported to the operations people is ignored, dismissed, discredited or simply not even acknowledged by a response from them.
The pilot fatigue issue is being captured in the data. My point was, the data is being strategically ignored (with corporate "justifications").
We have already, accidents directly attributed to crew fatigue - AA at Little Rock, MK at Halifax to cite two examples from memory, one domestic, one international. That, and crew reports as well as the available science on physiological effects of long wakefullness especially across time zones, (domestic or international).
The issues swirling about this thread have to do with human factors, and how the aviation system is addressing them - coming to terms through due process with them; One poster asked if I thought these issues were degrading professional standards - I said yes, they are. As always, there are pockets of "resistance" and pockets of concern with an overall highly successful safety record. It is trends and the nature and quality of recent accidents which is on safety people's radar. The accidents are not technical failures, bad weather, running into terrain, etc. They're loss of control and situational awareness as well as approach-landing accidents which were well outside stabilized approach criteria. These are bread-and-butter issues for this industry, but there they are - occuring. |We can see them in the data, now...today and have continued to report them. How clear must one be before someone "gets it" ?)
In terms of flight duy times alone, (and I dont' have my needle stuck on that single issue but I've done a career-load of long-haul and know the effects inside out), nothing has materially changed since the 70's and in Canada it's worse, where two crew members and a relief pilot (not certified/trained to takeoff or land - legally in the seat only at cruise altitudes) can be on duty for up to 20 hours, 23 in "unforseen circumstances". Where else except in the third world does such laxity obtain?
In terms of data use to assess trends in risk levels, the record is spotty at best and we are moving towards self-regulation in flight safety, with data collection and use being the center-piece of SMS. If the data is ignored by those responsible for cost control (flight operations management personnel), SMS is not being done. That is, in my view, a distinct, "clear and present" risk. While auditing by the regulator may discover such shortcomings, staffing levels within the government department cannot begin to deal with the work of actually sifting through and dealing with the results. The trend is toward "self-regulation", all the way down and the safety people know it.
There are a lot of people in the industry who comprehend all this very clearly and who have also commented here. This isn't "me" talking - this is the industry.
I hope too, with you, that others will at least offer a comment, perhaps even in disagreement - the dialogue is the thing, not "being right" or "succinct". There is much more to this than I am capable of expressing and we have seen a bit of this already.
Some safety folks don't recognize or properly use the data available to them. That's a big problem if it turns out to be pervasive.
The pilot fatigue problem is not being captured in the safety data and as such continues as an unabated and possibly increasing risk.
We have already, accidents directly attributed to crew fatigue - AA at Little Rock, MK at Halifax to cite two examples from memory, one domestic, one international. That, and crew reports as well as the available science on physiological effects of long wakefullness especially across time zones, (domestic or international).
The issues swirling about this thread have to do with human factors, and how the aviation system is addressing them - coming to terms through due process with them; One poster asked if I thought these issues were degrading professional standards - I said yes, they are. As always, there are pockets of "resistance" and pockets of concern with an overall highly successful safety record. It is trends and the nature and quality of recent accidents which is on safety people's radar. The accidents are not technical failures, bad weather, running into terrain, etc. They're loss of control and situational awareness as well as approach-landing accidents which were well outside stabilized approach criteria. These are bread-and-butter issues for this industry, but there they are - occuring. |We can see them in the data, now...today and have continued to report them. How clear must one be before someone "gets it" ?)
In terms of flight duy times alone, (and I dont' have my needle stuck on that single issue but I've done a career-load of long-haul and know the effects inside out), nothing has materially changed since the 70's and in Canada it's worse, where two crew members and a relief pilot (not certified/trained to takeoff or land - legally in the seat only at cruise altitudes) can be on duty for up to 20 hours, 23 in "unforseen circumstances". Where else except in the third world does such laxity obtain?
In terms of data use to assess trends in risk levels, the record is spotty at best and we are moving towards self-regulation in flight safety, with data collection and use being the center-piece of SMS. If the data is ignored by those responsible for cost control (flight operations management personnel), SMS is not being done. That is, in my view, a distinct, "clear and present" risk. While auditing by the regulator may discover such shortcomings, staffing levels within the government department cannot begin to deal with the work of actually sifting through and dealing with the results. The trend is toward "self-regulation", all the way down and the safety people know it.
There are a lot of people in the industry who comprehend all this very clearly and who have also commented here. This isn't "me" talking - this is the industry.
I hope too, with you, that others will at least offer a comment, perhaps even in disagreement - the dialogue is the thing, not "being right" or "succinct". There is much more to this than I am capable of expressing and we have seen a bit of this already.
Last edited by PJ2; 8th May 2009 at 06:16.
I hope too, with you, that others will at least offer a comment, perhaps even in disagreement - the dialogue is the thing, not "being right" or "succinct". There is much more to this than I am capable of expressing and we have seen a bit of this already.
I sense a degree of frustration on your part about the use of the data. I also agree that there will never be enough regulators to audit and indentify poor use of the data.
Of course in my many years I have come across the same. The way that it can be addressed is to promote a uniform process that forces the use of the data in a gated system approach. The regulator then audits that an approved system is in place without necessarily auditing dotting the eyes and crossing the tees. This method does require some buy-in by the stakeholders. This latter coment is a biggie and my words below may be beyond the interest of most thread readers.
1) You need buy-in by the stakeholders that there is a problem and addressing it will be good for all.
2) Proposals are then made for adoption of best practices (your bigger airlines probably have developed some of these already)
3) Several of the best practices are then identified for all to embrace that best fit their operations). Shake hands on this.
4) The regulators then follow up to identify which of these best practices have been adopted.
Now when/if an accident occurs the more advised in the industry (on boards like this) can point at the best practice that could have addressed the causal chain without blaming the crew or their culture.
And I realize that I am not addressing crew fatigue since I have no data other than ancendotal
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Pulitzer time
This is perhaps the most logical and non confrontational thread ever on Pprune.
No bitching, or "blaiming", (well almost), and a logical progress of thought trying to explain the accident factors and processes.
Would it be possible for the major contributors, to produce a combined document that covers this thread. In a PDF version, for presentation to management. As well as for back up resource for any Safety lectures.
ssa
No bitching, or "blaiming", (well almost), and a logical progress of thought trying to explain the accident factors and processes.
Would it be possible for the major contributors, to produce a combined document that covers this thread. In a PDF version, for presentation to management. As well as for back up resource for any Safety lectures.
ssa
FrequentSLF, IMHO your assumption goes too far (#65).
If ‘incompetence immunisation’ is having the required skills to undertake the job, then pilots are trained and checked to both have and maintain minimum standards. However, these may not qualify them individually, for dealing with all situations. In commercial aviation, there are instances where both crew are required to provide an acceptable level of safety, i.e. a training flight could have higher risk.
Skill is an acquired behaviour which has to be developed. Flying skills are relatively easy in modern aircraft, but ‘operating’ skills within the modern aviation system are more difficult to teach and improve – the problems of gaining experience in the digital world, hi tech etc.
One problem identified repeatedly in this forum is the human-automation interface; this is a complex subject where there are many differing types and standards of automation. Furthermore the implementation of automation (technology) can be quicker than changes in the bounding regulations or training (particularly the removal of old habits – changing skills). E.g. the 737 is a relatively old aircraft design, leading to a perception of inadequate automation. When operated ‘as designed’ its good and meets the safety requirement; however, if used in a complex situation, perhaps with a more recent hi tech operational philosophy (always use autos), then workload might increase and safety reduce, with opportunities for error.
Most of the piloting skills in flight operations are mental – hence my previous post re the need to train pilots to think. Thinking is a dominant element of professionalism ~ airmanship ~ (discipline, skill, proficiency, knowledge, situation awareness, judgement, - T. Kern).
Similarly, ‘training’ pilots for resistance to cultural issues is difficult; the extreme is like saying that pilots will not suffer errors. Cultural resistance, (national, organisational or professional culture) is also a thinking skill, closely associated with CRM training, but often not recognised in this area and hence not taught. Yet operators meet the requirements so perhaps the regulators need to take note.
‘Is the level of professionalism falling’?
Probably, when judged by the high ideals set by the professionals in the industry.
Possibly, when having to maintain a high level of safety in a rapidly changing (technical and economic) aviation system; pilots may be unable to acquire the necessary knowledge in the timescales available – this could be seen as a shortfall in training or poor professionalism.
‘Were they incompetent’; we wait for the safety reports.
If incompetent – lack of skills, then why … what was the standard of training provided, materials available, money, management policy, etc, etc; the conclusion cannot rest solely on the crew.
The alternative, that the crew had sufficient skills (a minimum for the task), but were these at the limits of human performance for the situation the crew encountered. As above, the investigation cannot stop there (pilot error). There should be judgement elsewhere on the required standards and if the crew met them. Were procedures / guidance to minimise error in such situations provided, were these the optimum, etc, etc. Why did the crew encounter such situation? These may be operator or regulator responsibilities.
Thus begs the question how deep do you go with the investigation. In my experience it has to be deep and practical enough to prevent another accident, but in this quickly evolving and complex world what are the timescales that an assessor has to consider?
If ‘incompetence immunisation’ is having the required skills to undertake the job, then pilots are trained and checked to both have and maintain minimum standards. However, these may not qualify them individually, for dealing with all situations. In commercial aviation, there are instances where both crew are required to provide an acceptable level of safety, i.e. a training flight could have higher risk.
Skill is an acquired behaviour which has to be developed. Flying skills are relatively easy in modern aircraft, but ‘operating’ skills within the modern aviation system are more difficult to teach and improve – the problems of gaining experience in the digital world, hi tech etc.
One problem identified repeatedly in this forum is the human-automation interface; this is a complex subject where there are many differing types and standards of automation. Furthermore the implementation of automation (technology) can be quicker than changes in the bounding regulations or training (particularly the removal of old habits – changing skills). E.g. the 737 is a relatively old aircraft design, leading to a perception of inadequate automation. When operated ‘as designed’ its good and meets the safety requirement; however, if used in a complex situation, perhaps with a more recent hi tech operational philosophy (always use autos), then workload might increase and safety reduce, with opportunities for error.
Most of the piloting skills in flight operations are mental – hence my previous post re the need to train pilots to think. Thinking is a dominant element of professionalism ~ airmanship ~ (discipline, skill, proficiency, knowledge, situation awareness, judgement, - T. Kern).
Similarly, ‘training’ pilots for resistance to cultural issues is difficult; the extreme is like saying that pilots will not suffer errors. Cultural resistance, (national, organisational or professional culture) is also a thinking skill, closely associated with CRM training, but often not recognised in this area and hence not taught. Yet operators meet the requirements so perhaps the regulators need to take note.
‘Is the level of professionalism falling’?
Probably, when judged by the high ideals set by the professionals in the industry.
Possibly, when having to maintain a high level of safety in a rapidly changing (technical and economic) aviation system; pilots may be unable to acquire the necessary knowledge in the timescales available – this could be seen as a shortfall in training or poor professionalism.
‘Were they incompetent’; we wait for the safety reports.
If incompetent – lack of skills, then why … what was the standard of training provided, materials available, money, management policy, etc, etc; the conclusion cannot rest solely on the crew.
The alternative, that the crew had sufficient skills (a minimum for the task), but were these at the limits of human performance for the situation the crew encountered. As above, the investigation cannot stop there (pilot error). There should be judgement elsewhere on the required standards and if the crew met them. Were procedures / guidance to minimise error in such situations provided, were these the optimum, etc, etc. Why did the crew encounter such situation? These may be operator or regulator responsibilities.
Thus begs the question how deep do you go with the investigation. In my experience it has to be deep and practical enough to prevent another accident, but in this quickly evolving and complex world what are the timescales that an assessor has to consider?
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Suggestion by SSA
Sounds like a good idea.
I have recently produced the paper I referred to above which I will be pleased to send to you if you like. It is philosophical rather than full of detail but it does highlight many of the points that I have raised or have been raised by others in this thread and may be of use / interest to you.
As I stated previously, there isn't a shortage of ideas, in fact, the opposite is true and maybe that is why it is so hard to make some serious progress. A paper that encompasses the best ideas and presents it to the aviation community via various periodicals and conferences may have the best chance of making a difference.
Despite the above and comments by others we have to remember that although safety should never be compromised there will always have be a compromise between operational excellence and commercial expediency. We have to accept that as a necessity and work with management and regulators to provide something that, while guaranteeing safety (as far as is possible), it does not impede commercial success - otherwise we will all be out of a job.
Thank you for your suggestion.
GW
I have recently produced the paper I referred to above which I will be pleased to send to you if you like. It is philosophical rather than full of detail but it does highlight many of the points that I have raised or have been raised by others in this thread and may be of use / interest to you.
As I stated previously, there isn't a shortage of ideas, in fact, the opposite is true and maybe that is why it is so hard to make some serious progress. A paper that encompasses the best ideas and presents it to the aviation community via various periodicals and conferences may have the best chance of making a difference.
Despite the above and comments by others we have to remember that although safety should never be compromised there will always have be a compromise between operational excellence and commercial expediency. We have to accept that as a necessity and work with management and regulators to provide something that, while guaranteeing safety (as far as is possible), it does not impede commercial success - otherwise we will all be out of a job.
Thank you for your suggestion.
GW
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alf5071h
You are right. My intention was to be "provocative" in a positive way.
I pushed a bit to the limit the rational but that has provoked two great replies, yours and P2J which have provided very exhaustive lines of thinking about the issues I have raised.
I am confident that you understand that I do not have the knowledge to even write half of what you and P2J have expressed on your posts. However let me say that I was expecting some replies on those lines.
I thank you for spending your time to write your post, which adds a lot to this thread.
If you allow me to comment the above
Do you mean that the industry standards of professionalism are set to high? I do not think that saying "the bar is set too high" means that the levels are falling. However if that is used an excuse (i.e. the bar is set too high to jump it) it is a symptom of falling professionalism.
The second part of your statement is the most intriguing. How to address it? Definitively airlines are always looking to expand the network and the frequency, which will mean shorter timescales. Is humanly possible to train "good" pilots in a shorter time? We might have nailed the nail right on the head.
Thanks once again
FSLF
IMHO your assumption goes too far
I pushed a bit to the limit the rational but that has provoked two great replies, yours and P2J which have provided very exhaustive lines of thinking about the issues I have raised.
I am confident that you understand that I do not have the knowledge to even write half of what you and P2J have expressed on your posts. However let me say that I was expecting some replies on those lines.
I thank you for spending your time to write your post, which adds a lot to this thread.
‘Is the level of professionalism falling’?
Probably, when judged by the high ideals set by the professionals in the industry.
Possibly, when having to maintain a high level of safety in a rapidly changing (technical and economic) aviation system; pilots may be unable to acquire the necessary knowledge in the timescales available – this could be seen as a shortfall in training or poor professionalism.
Probably, when judged by the high ideals set by the professionals in the industry.
Possibly, when having to maintain a high level of safety in a rapidly changing (technical and economic) aviation system; pilots may be unable to acquire the necessary knowledge in the timescales available – this could be seen as a shortfall in training or poor professionalism.
Do you mean that the industry standards of professionalism are set to high? I do not think that saying "the bar is set too high" means that the levels are falling. However if that is used an excuse (i.e. the bar is set too high to jump it) it is a symptom of falling professionalism.
The second part of your statement is the most intriguing. How to address it? Definitively airlines are always looking to expand the network and the frequency, which will mean shorter timescales. Is humanly possible to train "good" pilots in a shorter time? We might have nailed the nail right on the head.
Thanks once again
FSLF
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.
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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"To all concerned, get hold of a copy of James Reasons book "Human Error". Its all in there."
Besides heartily endorsing Reason's book, whose lessons appear central to this flight, I also recommend Perrow's "Normal Accidents" as well as Dorner's "The Logic of Failure," since the human element is but one part of the complex high risk overall system to be considered. All three are on my shelf.
Besides heartily endorsing Reason's book, whose lessons appear central to this flight, I also recommend Perrow's "Normal Accidents" as well as Dorner's "The Logic of Failure," since the human element is but one part of the complex high risk overall system to be considered. All three are on my shelf.