"To err is human": differing attitudes to mistakes in EK and Turkish accidents
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With the greatest respect .............
With the greatest respect I think we should now be focussing on Implementation rather than Reading Recommendations. It seems fairly obvious that we have had some well-informed opinions expressed here but the challenge is - and has been for all of my aviation career - getting those good ideas implemented.
If management are approached with long-winded academic arguments without a clearly-defined course of action, they will never buy into the proposal. They don't have time. Most of their day is spent putting out fires, and even though many of them may still be current, active pilots, you won't find one sitting at his / her desk with nothing to do but wait for the next good idea to coming breezing through the door. As we all know, if the CEO / Accountable Manager doesn't buy in to the idea, it probably isn't going to happen or, if it does, then there may only be lip service paid to it.
In many ways we are our own worst enemies. Compare the number of instances of pilots taking strike action over safety matters with the ones supporting industrial ones. In my previous airline the best-attended general meetings of the pilots were ones to do with conditions of service. It wasn't worth considering putting technical items on the agenda because no-one would show up. We need to get our own colleagues to buy into these ideas as much as we need management to do so.
This thread has shown that there are some good minds out there with ideas that warrant serious attention. We should maybe,
1. Gather the ideas
2. Collate and edit
3. Circulate for discussion and comment
4. Rewrite as necessary
5. Develop a plan for implementation
There is much, much more, but that could be a start.
GW
If management are approached with long-winded academic arguments without a clearly-defined course of action, they will never buy into the proposal. They don't have time. Most of their day is spent putting out fires, and even though many of them may still be current, active pilots, you won't find one sitting at his / her desk with nothing to do but wait for the next good idea to coming breezing through the door. As we all know, if the CEO / Accountable Manager doesn't buy in to the idea, it probably isn't going to happen or, if it does, then there may only be lip service paid to it.
In many ways we are our own worst enemies. Compare the number of instances of pilots taking strike action over safety matters with the ones supporting industrial ones. In my previous airline the best-attended general meetings of the pilots were ones to do with conditions of service. It wasn't worth considering putting technical items on the agenda because no-one would show up. We need to get our own colleagues to buy into these ideas as much as we need management to do so.
This thread has shown that there are some good minds out there with ideas that warrant serious attention. We should maybe,
1. Gather the ideas
2. Collate and edit
3. Circulate for discussion and comment
4. Rewrite as necessary
5. Develop a plan for implementation
There is much, much more, but that could be a start.
GW
Last edited by greywings; 8th May 2009 at 21:05.
GW;
I certainly concur with your views on implementation and CEO/Executive Management buy-in - if that isn't there, nothing else is going to happen. Also agree on the observation that nobody has the time to read - and it is really obvious when trying to open a safety discussion with flight operations people - their eyes glaze over instantly.
But educating themselves is their responsibility and at some point the buck has to stop with those in charge. Reading is part of the education on the safety work necessary to run any airline.
All that said, you can lead a horse to water...
Re implementation, here's one way:
After a long period (five years) in what we expected would be an automatic buy-in to data analysis because of what was in the data, (some not very pretty events), and the need was so "obvious", there was still nothing - no interest, no engagement, no support other than the lip-service we're all familiar with. For some strange reason, while other aspects of the safety culture were excellent, nobody wanted to know what was in the data, but they kept collecting it. That was how we understood it and perceived it.
So through a series of techniques, we began showing the pilots themselves what was in the data which included some "interesting" incidents. The reported disbelief was really interesting; - "that was one of us?" was a common reaction. Sometimes we contacted crews but we never judged, we just presented and answered questions where we could from what was in the data. We never went public and never embarrassed or disrespected any crews or the organization. It took a long time.
It was only after we began doing that, that things began to slowly change. Our confidentiality processes were such that it was impossible to find out who the crew was in the data - it was all about "what" and never about "who". Our FOQA Agreement had absolutely clear mandates to which both the pilots' association and airline management were signatories. We stayed strictly apart from any industrial aspect and to everyone's credit, such an approach was never attempted.
The reporting culture is superb. It is confidential and risk-free under an excellent safety policy - these are part of building the tools that need to be in place. Instead of continuing to push rope, we went directly to the pilots and it seems to be working. That was one way to get something implemented. There are others.
I certainly concur with your views on implementation and CEO/Executive Management buy-in - if that isn't there, nothing else is going to happen. Also agree on the observation that nobody has the time to read - and it is really obvious when trying to open a safety discussion with flight operations people - their eyes glaze over instantly.
But educating themselves is their responsibility and at some point the buck has to stop with those in charge. Reading is part of the education on the safety work necessary to run any airline.
All that said, you can lead a horse to water...
Re implementation, here's one way:
After a long period (five years) in what we expected would be an automatic buy-in to data analysis because of what was in the data, (some not very pretty events), and the need was so "obvious", there was still nothing - no interest, no engagement, no support other than the lip-service we're all familiar with. For some strange reason, while other aspects of the safety culture were excellent, nobody wanted to know what was in the data, but they kept collecting it. That was how we understood it and perceived it.
So through a series of techniques, we began showing the pilots themselves what was in the data which included some "interesting" incidents. The reported disbelief was really interesting; - "that was one of us?" was a common reaction. Sometimes we contacted crews but we never judged, we just presented and answered questions where we could from what was in the data. We never went public and never embarrassed or disrespected any crews or the organization. It took a long time.
It was only after we began doing that, that things began to slowly change. Our confidentiality processes were such that it was impossible to find out who the crew was in the data - it was all about "what" and never about "who". Our FOQA Agreement had absolutely clear mandates to which both the pilots' association and airline management were signatories. We stayed strictly apart from any industrial aspect and to everyone's credit, such an approach was never attempted.
The reporting culture is superb. It is confidential and risk-free under an excellent safety policy - these are part of building the tools that need to be in place. Instead of continuing to push rope, we went directly to the pilots and it seems to be working. That was one way to get something implemented. There are others.
Greywings
I take your points and clarity of expression.
With the greatest respect I think we should now be focussing on Implementation rather than Reading Recommendations. It seems fairly obvious that we have had some well-informed opinions expressed here but the challenge is - and has been for all of my aviation career - getting those good ideas implemented
We need to move off the identification issue of who screwed up and onto the corrective action issues following an accident, else why bother even investigating accidents.
I'm not a fan of more regulation is good basically beacause I don't trust that the regulator really has all the answers. The end user can more clearly see the problems given enough vision. It's the lack of vision or willingness to open ones eyes that is the problem.
I have been impressed with the magnitude of data and understanding that exist in totality in our industry and is readily available through the safety professionals and offices in our industry. Yes I recognize that these same professionals are often busy putting out fires and thus justifying their day to day jobs.
But in my view there is nothing wrong in calling a group of these experts together to share "best practices" on issues that we all agree are important to our industry's view by the public. Once this is done then and only then should the regulator enter the arena if only to take credit for overseeing such best practices.
I suspect that this thread may have drifted off the idea of Rumors & News but I appologize that my initial intent was to stop people from viewing an accident thread dujour as one where they could most easily find fault with who/what caused the accident in the first place.
It's OK with me that the contributors take this thread to where they want.
I take your points and clarity of expression.
With the greatest respect I think we should now be focussing on Implementation rather than Reading Recommendations. It seems fairly obvious that we have had some well-informed opinions expressed here but the challenge is - and has been for all of my aviation career - getting those good ideas implemented
I'm not a fan of more regulation is good basically beacause I don't trust that the regulator really has all the answers. The end user can more clearly see the problems given enough vision. It's the lack of vision or willingness to open ones eyes that is the problem.
I have been impressed with the magnitude of data and understanding that exist in totality in our industry and is readily available through the safety professionals and offices in our industry. Yes I recognize that these same professionals are often busy putting out fires and thus justifying their day to day jobs.
But in my view there is nothing wrong in calling a group of these experts together to share "best practices" on issues that we all agree are important to our industry's view by the public. Once this is done then and only then should the regulator enter the arena if only to take credit for overseeing such best practices.
I suspect that this thread may have drifted off the idea of Rumors & News but I appologize that my initial intent was to stop people from viewing an accident thread dujour as one where they could most easily find fault with who/what caused the accident in the first place.
It's OK with me that the contributors take this thread to where they want.
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PJ, lomapaseo et al
Thank you for a truly interesting and stimulating discussion on an important issue. Although we may have strayed away slightly from the original thread (many thanks to Gibon2), the ground that we have covered has been relevant and productive. Clearly, amongst others, PJ and colleagues have made enormous progress with their safety programme(s) and are to be congratulated. Regrettably, others live and work within a culture that would seem foreign to those of us who enjoy enlightened and professional debate - and subsequent action.
I have spent many years working in cross-cultural environments and know that 'authority gradients' (for instance) play their part in degrading or, in some instances, enhancing crew performance. However, I think it is true to say that, at the end of the day, a pilot who truly loves what he / she does and strives for the highest professional standards will perform to a universally-acceptable standard. I had the great pleasure of serving IFALPA as a Regional Vice-President for a while and was occasionally appalled at the primitive standards that prevailed in some airlines. Frequently, and more often than not, their pilots sought help because they wanted to be amongst the best but lacked the resources to be so. Naturally, others, more fortunate than themselves, were usually happy to help.
Various situations in the past have demonstrated that we are far from being a 'happy band of bothers', in fact, just another group of professionals with mortgages, family and other commitments. If we are to make any serious progress and have pilot-ing accorded the respect that other professions have, we need to unite behind a banner of pride in what we do and care for those we serve. I am not sure where we began to lose our way but I think that we have strayed too far from the reputation that we had as leaders rather than followers, and have lost the respect of those outside of our profession who tend to believe the numbskull reporting that depicts us as merely button-pushers.
We need to come together to demonstrate that being a pilot is not only tremendously rewarding personally but provides an invaluable service to the global community.
We need to become leaders again.
GW
I have spent many years working in cross-cultural environments and know that 'authority gradients' (for instance) play their part in degrading or, in some instances, enhancing crew performance. However, I think it is true to say that, at the end of the day, a pilot who truly loves what he / she does and strives for the highest professional standards will perform to a universally-acceptable standard. I had the great pleasure of serving IFALPA as a Regional Vice-President for a while and was occasionally appalled at the primitive standards that prevailed in some airlines. Frequently, and more often than not, their pilots sought help because they wanted to be amongst the best but lacked the resources to be so. Naturally, others, more fortunate than themselves, were usually happy to help.
Various situations in the past have demonstrated that we are far from being a 'happy band of bothers', in fact, just another group of professionals with mortgages, family and other commitments. If we are to make any serious progress and have pilot-ing accorded the respect that other professions have, we need to unite behind a banner of pride in what we do and care for those we serve. I am not sure where we began to lose our way but I think that we have strayed too far from the reputation that we had as leaders rather than followers, and have lost the respect of those outside of our profession who tend to believe the numbskull reporting that depicts us as merely button-pushers.
We need to come together to demonstrate that being a pilot is not only tremendously rewarding personally but provides an invaluable service to the global community.
We need to become leaders again.
GW
FrequentSLF, thanks … particularly for the provocation ( ‘po’ – de Bono).
Re: “… standards of professionalism are set to high.” (#78)
No I do not think so. Standards when set are aspects of professionalism, not professionalism it self, i.e. skill, or knowledge.
My view of professionalism includes a never ending objective of self-improvement, and as long as individuals in the industry maintain this ethos we should be able to maintain a high level of professionalism.
However, therein is a significant problem; how to maintain these standards in a rapidly changing social environment – how prevent professionalism deteriorating which I fear it is.
Pilots and other professionals are challenged by an evolving ‘culture’ of instant gratification, self centeredness, low respect, deficient self esteem, and under confidence (‘Beyond Feelings’ – Ruggiero). What is there to look forward to beyond the age of 40 when pilots can become Captains in their late 20s/early 30s?
Re: “How to address it. … can we provide good pilots in a shorter time”.
I doubt that training timescales can be reduced; risks – opportunities for error increase during times of change, so seeking an improvement might cause more problems.
IMHO current ‘post graduate’ training is not providing new pilots with the skills, or the other constituents of professionalism, to cope with the demands of a technologically changing industry. We fly reliable aircraft yet focus on failure, we require flexibility but operate in constrained airspace and ‘have to follow procedures’, there is increasing regulation, etc, etc. Thus, there are fewer opportunities to learn from failure, from minor errors, or particularly from senior pilots, as the majority of them are also children of the technological age (but not the real ‘oldies’).
Pilots acquire knowledge and basic flying skills during ab-initio training. However, the practical application – tacit knowledge, the know-how as opposed to know-what, is more difficult to acquire; ‘on-the-job-learning’.
This requires experience in situ, guidance from others, and self-reflection to facilitate learning. As above, the opportunities for this are reducing, Captains should coach the less experienced pilots (increasing workload), and we all need to debrief every flight – reflect on what has been learnt – self improvement, the reinforcement of our professional ethos. There are weaknesses in all of these areas.
Note the range of questions in this forum – more ‘how to do it’ than requests for pure technical knowledge.
Consider the ‘signal to noise ratio’ of forum posts – ‘signal’ is knowledgeable information, opposed to the noise of supposition, myth, or bias. There is an increasing amount of noise, similar to the world-at-large, e.g. sensationalist media reporting or more regulation (verbiage); there are far fewer ‘signals’ of value.
Whatever problems the industry faces in this changing world, it is unlikely that they will diminish, thus the industry has to live with them – we have to adapt.
How can we adapt … how do we address it? Perhaps the other discussion in this thread is considering this, - how people have adapted or what is required to adapt.
Given that humans are very good at adapting, we will change; but will it be in time and without significant risk?
Re: “… standards of professionalism are set to high.” (#78)
No I do not think so. Standards when set are aspects of professionalism, not professionalism it self, i.e. skill, or knowledge.
My view of professionalism includes a never ending objective of self-improvement, and as long as individuals in the industry maintain this ethos we should be able to maintain a high level of professionalism.
However, therein is a significant problem; how to maintain these standards in a rapidly changing social environment – how prevent professionalism deteriorating which I fear it is.
Pilots and other professionals are challenged by an evolving ‘culture’ of instant gratification, self centeredness, low respect, deficient self esteem, and under confidence (‘Beyond Feelings’ – Ruggiero). What is there to look forward to beyond the age of 40 when pilots can become Captains in their late 20s/early 30s?
Re: “How to address it. … can we provide good pilots in a shorter time”.
I doubt that training timescales can be reduced; risks – opportunities for error increase during times of change, so seeking an improvement might cause more problems.
IMHO current ‘post graduate’ training is not providing new pilots with the skills, or the other constituents of professionalism, to cope with the demands of a technologically changing industry. We fly reliable aircraft yet focus on failure, we require flexibility but operate in constrained airspace and ‘have to follow procedures’, there is increasing regulation, etc, etc. Thus, there are fewer opportunities to learn from failure, from minor errors, or particularly from senior pilots, as the majority of them are also children of the technological age (but not the real ‘oldies’).
Pilots acquire knowledge and basic flying skills during ab-initio training. However, the practical application – tacit knowledge, the know-how as opposed to know-what, is more difficult to acquire; ‘on-the-job-learning’.
This requires experience in situ, guidance from others, and self-reflection to facilitate learning. As above, the opportunities for this are reducing, Captains should coach the less experienced pilots (increasing workload), and we all need to debrief every flight – reflect on what has been learnt – self improvement, the reinforcement of our professional ethos. There are weaknesses in all of these areas.
Note the range of questions in this forum – more ‘how to do it’ than requests for pure technical knowledge.
Consider the ‘signal to noise ratio’ of forum posts – ‘signal’ is knowledgeable information, opposed to the noise of supposition, myth, or bias. There is an increasing amount of noise, similar to the world-at-large, e.g. sensationalist media reporting or more regulation (verbiage); there are far fewer ‘signals’ of value.
Whatever problems the industry faces in this changing world, it is unlikely that they will diminish, thus the industry has to live with them – we have to adapt.
How can we adapt … how do we address it? Perhaps the other discussion in this thread is considering this, - how people have adapted or what is required to adapt.
Given that humans are very good at adapting, we will change; but will it be in time and without significant risk?
East is East and West is West and never the twain will meet.
In terms of flight safety, culture has great significance. I recall where an Air Japan (?) DC8 crashed into the Bay of Tokyo piloted by a captain intent on suicide. The last words on the CVR was that of his first officer pleading to the captain not to "kill us all" Culture prevented the F/O from taking positive action to prevent the tragedy. There are countless examples of aircraft accidents in which ethnic culture played a deadly part. As they say "Watch this space" and wait for the next culture driven accident.
The culture of the West (Europe and the Americas) will always be very different from that of the East (Asia). (Twain means “two.”) This saying is part of the refrain of “The Ballad of East and West,” a poem by Rudyard Kipling
“East is East and West is West”
This might be just an ‘artistic’ cultural view, whereas there are many more components in an ‘aviation’ culture – things that affect the way we behave.
“Culture” – what we do when no one is looking.
Professionalism and Culture are linked; perhaps professionalism is an outward indication of culture. I associate professionalism with airmanship, thus good airmanship might reflect aspects of a positive culture, but exhibiting good airmanship is not necessarily related to national culture.
“East is East and West is West”, could be equated to “those who have encountered a serious error, and those who will”.
The different views of error amongst the professionals might originate from how individuals consider the outcome of an encounter. There are those who ask ‘why’, seeking a deeper understanding of the human involvement and the situation, and thus learn from mistakes. Alternatively, some pilots will dismiss the encounter – ‘it was just me’, they consider that it won’t happen again, but without understanding why; this view leads towards an attitude of invulnerability.
Some academic views indicate similar divisions. Error either originates from the situation, and the human is pawn in the proceedings, or error commences with the individual – who may generate the situation, and human behaviour or limitations dictate the outcome.
At a practical level these views might be one and the same, or that individually, both contribute to the process of error.
The differences amongst pilot may just be their choice of view – situation or individual, or particularly which end of the error tunnel they look down. A backward look encourages hindsight bias, whereas attempting to see the situation as if they are person in the error path might open many more alternatives.
This is similar to reactive and proactive views of safety. Neither should dominate, we require both to be successful. As the industry improves safety (reactive bias), it is approaching an asymptotic level - “The paradoxes of almost totally safe transportation systems”. This paper argues that as total safety is approached, we need to bias more towards proactive safety.
The differences in pilot attitude to error may just reflect these different views of safety or the emphasis placed on them – reactive, blaming, fix the problems of this accident; or proactive, understanding, prepare defenses for a range of accident situations.
The next culture driven accident is just as likely to be dominated by poor corporate culture as it is by poor professionalism, it depends which one dominates; then again there are other aspects of a dominant culture.
This might be just an ‘artistic’ cultural view, whereas there are many more components in an ‘aviation’ culture – things that affect the way we behave.
“Culture” – what we do when no one is looking.
Professionalism and Culture are linked; perhaps professionalism is an outward indication of culture. I associate professionalism with airmanship, thus good airmanship might reflect aspects of a positive culture, but exhibiting good airmanship is not necessarily related to national culture.
“East is East and West is West”, could be equated to “those who have encountered a serious error, and those who will”.
The different views of error amongst the professionals might originate from how individuals consider the outcome of an encounter. There are those who ask ‘why’, seeking a deeper understanding of the human involvement and the situation, and thus learn from mistakes. Alternatively, some pilots will dismiss the encounter – ‘it was just me’, they consider that it won’t happen again, but without understanding why; this view leads towards an attitude of invulnerability.
Some academic views indicate similar divisions. Error either originates from the situation, and the human is pawn in the proceedings, or error commences with the individual – who may generate the situation, and human behaviour or limitations dictate the outcome.
At a practical level these views might be one and the same, or that individually, both contribute to the process of error.
The differences amongst pilot may just be their choice of view – situation or individual, or particularly which end of the error tunnel they look down. A backward look encourages hindsight bias, whereas attempting to see the situation as if they are person in the error path might open many more alternatives.
This is similar to reactive and proactive views of safety. Neither should dominate, we require both to be successful. As the industry improves safety (reactive bias), it is approaching an asymptotic level - “The paradoxes of almost totally safe transportation systems”. This paper argues that as total safety is approached, we need to bias more towards proactive safety.
The differences in pilot attitude to error may just reflect these different views of safety or the emphasis placed on them – reactive, blaming, fix the problems of this accident; or proactive, understanding, prepare defenses for a range of accident situations.
The next culture driven accident is just as likely to be dominated by poor corporate culture as it is by poor professionalism, it depends which one dominates; then again there are other aspects of a dominant culture.
PJ2, Greywings, et al,
This has been one of the most interesting and professional threads I have read. In another life I was both a flight instructor/IRE/TRE and pilot manager and what you have had to say about safety management and all its surrounding processes is excellent. Thank you for such a stimlating discussion.
This has been one of the most interesting and professional threads I have read. In another life I was both a flight instructor/IRE/TRE and pilot manager and what you have had to say about safety management and all its surrounding processes is excellent. Thank you for such a stimlating discussion.
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alf5071h
sorry for the late reply...I was on duty
Well....the title of the thread says "Err is human"...in Latin the complete sentence is "Errare humanum est, perseverare diabolicum"...
I believe the industry is working hard to forget and delete the last part of such sentence. However as you said the working environment is changing so fast that we should always consider the complete sentence.
“East is East and West is West”
Being an Italian and living in Malaysia for 17 years I cannot agree more with your post!
Cheers
sorry for the late reply...I was on duty
Given that humans are very good at adapting, we will change; but will it be in time and without significant risk?
I believe the industry is working hard to forget and delete the last part of such sentence. However as you said the working environment is changing so fast that we should always consider the complete sentence.
“East is East and West is West”
Being an Italian and living in Malaysia for 17 years I cannot agree more with your post!
Cheers
For others who like I may not have appreciated the full quotation:
Errare humanum est, perseverare diabolicum - 'to err is human, but to persist is diabolical.' - Seneca.
A more recent version might be:
“Somebody does somethin' stupid, that's human. They don't stop when they see it's wrong, that's a fool.” - Elvis Presley.
I won’t persist with the discussion for fear that I be associated with the quote …
Errare humanum est, perseverare diabolicum - 'to err is human, but to persist is diabolical.' - Seneca.
A more recent version might be:
“Somebody does somethin' stupid, that's human. They don't stop when they see it's wrong, that's a fool.” - Elvis Presley.
I won’t persist with the discussion for fear that I be associated with the quote …
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To cut through all the bs...it's blatant racism, pure and simple. You can articulate and spin all you want: both the Turkish crew and the EK crew made crucial mistakes, only the element of luck prevented a disaster at Tullamrine.
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Bergerie1, Kalistan .............
Bergerie1, thank you for your comments. I have been fortunate to have spent my aviation career in the company of like-minded professionals of all colour, creed and ethnicity. Our 'differences' were ignored when we came together as aviators, proud of our profession and of our dedication to serving the travelling public to the best of our ability. Although I sympathise with the comments made by Kalistan, I would recommend a thorough re-reading of the previous posts, as I think it will become obvious that, apart from one recent post, the comments were 'racism-neutral'.
It is quite correct to say that there are close correlations between the Emirates and Turkish airline accidents. Emirates were lucky and Turkish were not. That really should not be the issue. The issue is why professional aviators make mistakes of such proportion. Is there a cultural factor that we have ignored? Is fatigue more insidious than we realise? Or are accidents merely an example of the randomness of the behaviour of complicated technical / human systems?
In my former life I had the great pleasure of working with some of the industry's best minds: Japanese, Australian, British, American and, in more recent years, Chinese, as well as others. No one culture has a monopoloy on commonsense and airmanship. True, we often view the world from different perspectives but we all strive for the same thing.
If we persist in bad-mouthing others because they come from a different part of the world, we, as an industry, will lose our credibility and the ability to influence - positively - the way it will develop in the future.
Best wishes,
GW
It is quite correct to say that there are close correlations between the Emirates and Turkish airline accidents. Emirates were lucky and Turkish were not. That really should not be the issue. The issue is why professional aviators make mistakes of such proportion. Is there a cultural factor that we have ignored? Is fatigue more insidious than we realise? Or are accidents merely an example of the randomness of the behaviour of complicated technical / human systems?
In my former life I had the great pleasure of working with some of the industry's best minds: Japanese, Australian, British, American and, in more recent years, Chinese, as well as others. No one culture has a monopoloy on commonsense and airmanship. True, we often view the world from different perspectives but we all strive for the same thing.
If we persist in bad-mouthing others because they come from a different part of the world, we, as an industry, will lose our credibility and the ability to influence - positively - the way it will develop in the future.
Best wishes,
GW
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alf5071h
This is similar to reactive and proactive views of safety. Neither should dominate, we require both to be successful. As the industry improves safety (reactive bias), it is approaching an asymptotic level - “The paradoxes of almost totally safe transportation systems”. This paper argues that as total safety is approached, we need to bias more towards proactive safety.
Some years ago, I was in a conversation with a relative who was running a fairly large and respected airline that was about to introduce the 767. His background included flying a large number of multiengine types, starting with underpowered beasties flown under trying circumstances in the years immediately before 1945.
His concern was that the approach and landing on a 767 was so smooth and uneventful compared with the need to wrestle to the ground the current type in the airline fleet, particularly in any sort of a cross wind, that he worried that, in due course, there would be an accident as the PF would not be ‘on the edge of his seat’ and thus insufficiently in the loop to react in a timely fashion.
An observation of possible circumstances that I suspect require a mixture of both reactive and proactive safety to counter, probably biased to proactive; and I doubt have got any simpler to manage with the passage of time.
This is similar to reactive and proactive views of safety. Neither should dominate, we require both to be successful. As the industry improves safety (reactive bias), it is approaching an asymptotic level - “The paradoxes of almost totally safe transportation systems”. This paper argues that as total safety is approached, we need to bias more towards proactive safety.
Some years ago, I was in a conversation with a relative who was running a fairly large and respected airline that was about to introduce the 767. His background included flying a large number of multiengine types, starting with underpowered beasties flown under trying circumstances in the years immediately before 1945.
His concern was that the approach and landing on a 767 was so smooth and uneventful compared with the need to wrestle to the ground the current type in the airline fleet, particularly in any sort of a cross wind, that he worried that, in due course, there would be an accident as the PF would not be ‘on the edge of his seat’ and thus insufficiently in the loop to react in a timely fashion.
An observation of possible circumstances that I suspect require a mixture of both reactive and proactive safety to counter, probably biased to proactive; and I doubt have got any simpler to manage with the passage of time.
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Contributing Factors on TK accident
In Addition to 757 driver comments on the authoritive nature and the culture ,also the Military backround of some of thier Captains, not in thier nature to aply effective CRM in the cockpit.
This is labled as one of several hazards in aviation . It was very visible in the several accidents by Korean Airlines in the past as they had recruited from the airforce with the same behavior untill it was ironed out buy intense organisational changes.
This is labled as one of several hazards in aviation . It was very visible in the several accidents by Korean Airlines in the past as they had recruited from the airforce with the same behavior untill it was ironed out buy intense organisational changes.
Greywings:
Very well and appropriately stated. Cheers to you sir.
Bergerie1;
Indeed, to echo Greywings, thank you - it's gratifying that such input is valuable to some. I have been writing about these issues for about a dozen years from within a major carrier with whom I worked as well as on various aviation forums. While one never expects an airline's management to hearken to an anonymous forum for "advice", and because management's job is to, a) pluck the most feathers from the goose with minimum hissing, (max productivity, minimum money/working conditions), and, b) to make a profit at all cost (I know such a comment may be accused of being hyperbole in most cases but not some that I've witnessed internally) they won't listen to this kind of input even if they read it, at least this kind of rational and non-agenda'd discussion helps others who may not be aware that their flight operations departments are not concerned with safety but with profit, (forced into the position by deregulatory pressures and shareholder demands for "instant results"). With few exceptions most safety departments are seen as corporate bureaucratic backwaters, viewed derisively as career dead-ends with little glamour and even less benefit (due to the ignorant "millstone around profit's neck" impression most have of the work).
I would challenge any, no, every airline CEO to state what she or he knows about flight safety and specifically about their own airline's safety programs and processes, not, obviously, because they need to run the program or even supervise it but because they absolutely must support it with comprehension so that they can lead, and, where needed, defend expenditures which are viewed as unnecessary by the less-informed, and to remind all those underneath of the business they are all engaged in - the fundamental insurance policy of aviation. Frankly however, in my experience they know little to nothing about the processes and don't know risk from a balance sheet - many don't even know the nature of the business they're in, so far away are they from what "aviation is" and what it requires. For some, it's simply another cash-cow with extorted largesse, (pay me well or I'll leave you).
The entire story of deregulation, (both in the financial sector and, for decades now in the aviation sector) has been about the gradual removal of "layers of cheese", so to speak, under the illusion of the "normalization of deviance" - the notion that "expensive" layers of safety defence can be removed without resulting decreases in safety (because knowledge of how the present excellent record got that way does not exist within airline managments), but with a commensurate increase in profit, a very "desireable result" so far as bottom-line thinking goes. The stupidity and commensurate risk of such an approach is, many believe, now showing itself. There are too many polished-but-ignorant MBA's and Marketing experts and not enough people who know the smell of kerosene. Both are necessary but it is time to re-balance and re-dedicate a knowledge of aviation and not just of spreadsheets and ASMs etc.
The psychology of "cost vs benefit" is what they know and therefore they neither can make the connection to complex safety processes nor comprehend why pilot training, reasonable wages, working conditions which attend to fatigue issues, sick-pay programs which do not financially punish pilots for booking off when they ought to and so on should be both understood and led by top management so that such programs remain effective "layers of cheese".
With these "glasses" on, we can see quite easily why aviation has gone the way it has and why the fatal accident rate is going to rise because airlines have been dismantling or even ignoring these trends out of a sense of satisfaction with the present level of safety and risk. The safety conferences I have attended have long said otherwise and have cautioned airlines against this but to no avial.
Instead, as always in aviation, managements must learn the hard way, and the preventative programs in place, while effective where installed and actually employed by the carrier, remain secondary alternatives to kicking tin and managing the publicity disaster that a fatal accident always brings to an airline.
The thread on the Colgan accident is especially painful to read because the accident was both predictable and therefore preventable - not before the actual flight but years ago when airline managements began desecrating the career of the professional pilot on their way to satisfying the demands of a profit-driven enterprise.
The chickens are coming home to roost, right at the point in aviation's history where a good safety initiative is being implemented very poorly, with few resources, little regulatory oversight and no comprehension by anyone: SMS. As it is being presently implemented, it is nothing less than the de-regulation of flight safety. The record is already established and, if not addressed the trend will continue: Airlines have already tried to get away with substandard operations beyond the eye of the regulator and, where commercial pressures are high and visibility, (the chance of being caught) is low, the choice may invariably be in favour of commercial priorities.
These are large patterns which must be examined from "afar" - they cannot be seen in the individual flights or pilots or managements. Yet no one is examining the industry thus.
While a wholesale examination and change is neither possible nor necessary because the fundamentals are sound, (it is the trends, not the foundations that are disconcerting), certainly an examination of the factors set out in this thread are in order.
As an aside, or more bluntly a diversion, (it has been discussed here before), there is very little difference between what has been happening to aviation, and what has happened (since the early '70's) to the U.S. economy which resulted in it's own "fatal accident" last October thanks to massive de-regulatory initiatives. Though the outcomes look different, the principles are the same - there are important lessons here for both.
If we persist in bad-mouthing others because they come from a different part of the world, we, as an industry, will lose our credibility and the ability to influence - positively - the way it will develop in the future.
Bergerie1;
Indeed, to echo Greywings, thank you - it's gratifying that such input is valuable to some. I have been writing about these issues for about a dozen years from within a major carrier with whom I worked as well as on various aviation forums. While one never expects an airline's management to hearken to an anonymous forum for "advice", and because management's job is to, a) pluck the most feathers from the goose with minimum hissing, (max productivity, minimum money/working conditions), and, b) to make a profit at all cost (I know such a comment may be accused of being hyperbole in most cases but not some that I've witnessed internally) they won't listen to this kind of input even if they read it, at least this kind of rational and non-agenda'd discussion helps others who may not be aware that their flight operations departments are not concerned with safety but with profit, (forced into the position by deregulatory pressures and shareholder demands for "instant results"). With few exceptions most safety departments are seen as corporate bureaucratic backwaters, viewed derisively as career dead-ends with little glamour and even less benefit (due to the ignorant "millstone around profit's neck" impression most have of the work).
I would challenge any, no, every airline CEO to state what she or he knows about flight safety and specifically about their own airline's safety programs and processes, not, obviously, because they need to run the program or even supervise it but because they absolutely must support it with comprehension so that they can lead, and, where needed, defend expenditures which are viewed as unnecessary by the less-informed, and to remind all those underneath of the business they are all engaged in - the fundamental insurance policy of aviation. Frankly however, in my experience they know little to nothing about the processes and don't know risk from a balance sheet - many don't even know the nature of the business they're in, so far away are they from what "aviation is" and what it requires. For some, it's simply another cash-cow with extorted largesse, (pay me well or I'll leave you).
The entire story of deregulation, (both in the financial sector and, for decades now in the aviation sector) has been about the gradual removal of "layers of cheese", so to speak, under the illusion of the "normalization of deviance" - the notion that "expensive" layers of safety defence can be removed without resulting decreases in safety (because knowledge of how the present excellent record got that way does not exist within airline managments), but with a commensurate increase in profit, a very "desireable result" so far as bottom-line thinking goes. The stupidity and commensurate risk of such an approach is, many believe, now showing itself. There are too many polished-but-ignorant MBA's and Marketing experts and not enough people who know the smell of kerosene. Both are necessary but it is time to re-balance and re-dedicate a knowledge of aviation and not just of spreadsheets and ASMs etc.
The psychology of "cost vs benefit" is what they know and therefore they neither can make the connection to complex safety processes nor comprehend why pilot training, reasonable wages, working conditions which attend to fatigue issues, sick-pay programs which do not financially punish pilots for booking off when they ought to and so on should be both understood and led by top management so that such programs remain effective "layers of cheese".
With these "glasses" on, we can see quite easily why aviation has gone the way it has and why the fatal accident rate is going to rise because airlines have been dismantling or even ignoring these trends out of a sense of satisfaction with the present level of safety and risk. The safety conferences I have attended have long said otherwise and have cautioned airlines against this but to no avial.
Instead, as always in aviation, managements must learn the hard way, and the preventative programs in place, while effective where installed and actually employed by the carrier, remain secondary alternatives to kicking tin and managing the publicity disaster that a fatal accident always brings to an airline.
The thread on the Colgan accident is especially painful to read because the accident was both predictable and therefore preventable - not before the actual flight but years ago when airline managements began desecrating the career of the professional pilot on their way to satisfying the demands of a profit-driven enterprise.
The chickens are coming home to roost, right at the point in aviation's history where a good safety initiative is being implemented very poorly, with few resources, little regulatory oversight and no comprehension by anyone: SMS. As it is being presently implemented, it is nothing less than the de-regulation of flight safety. The record is already established and, if not addressed the trend will continue: Airlines have already tried to get away with substandard operations beyond the eye of the regulator and, where commercial pressures are high and visibility, (the chance of being caught) is low, the choice may invariably be in favour of commercial priorities.
These are large patterns which must be examined from "afar" - they cannot be seen in the individual flights or pilots or managements. Yet no one is examining the industry thus.
While a wholesale examination and change is neither possible nor necessary because the fundamentals are sound, (it is the trends, not the foundations that are disconcerting), certainly an examination of the factors set out in this thread are in order.
As an aside, or more bluntly a diversion, (it has been discussed here before), there is very little difference between what has been happening to aviation, and what has happened (since the early '70's) to the U.S. economy which resulted in it's own "fatal accident" last October thanks to massive de-regulatory initiatives. Though the outcomes look different, the principles are the same - there are important lessons here for both.
Last edited by PJ2; 27th May 2009 at 15:29.
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>"Layers of cheese"...
Unusual analogy but it does occur to me that it just may be an apt one! That final layer of cheese has no warning on it. It appears to be just another way for the MBA bean-counter to slice a few cents from some cost-center somewhere.
When a craps dealer doesn't know the proper payout he can simply drop chips onto the layout until the player cracks a smile and then take back one chip. The feedback from the player is immediate and there is but one factor involved. With a bean-counter cutting corners it may be a long time before there are a sufficient chain of events to provide any feedback. And then its too late to take back that last layer of cheese!
I recall reading decades ago about a small plane that had gone through nine "cheapie annuals" until the tenth annual inspection found an altimeter that had been recalled by the manufacturer ten years prior to the inspection. You get what you pay for.
Unusual analogy but it does occur to me that it just may be an apt one! That final layer of cheese has no warning on it. It appears to be just another way for the MBA bean-counter to slice a few cents from some cost-center somewhere.
When a craps dealer doesn't know the proper payout he can simply drop chips onto the layout until the player cracks a smile and then take back one chip. The feedback from the player is immediate and there is but one factor involved. With a bean-counter cutting corners it may be a long time before there are a sufficient chain of events to provide any feedback. And then its too late to take back that last layer of cheese!
I recall reading decades ago about a small plane that had gone through nine "cheapie annuals" until the tenth annual inspection found an altimeter that had been recalled by the manufacturer ten years prior to the inspection. You get what you pay for.
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This just gets better ............
PeeJay et al,
What an interesting and thought-provoking thread this is turning out to be. Hopefully, we can continue to attract more contributors and thus more good ideas.
I would like to take up on a couple of points before digressing slightly.
'Management' comes in for a lot of stick, and much of it is justified. PJ alluded to a typical CEO having little or no understanding of the intricacies of an SMS and called into question the validity of MBA's standing in our industry. Both very valid points. However, airline managers - in many cases - are not carefully nurtured as they are in many other industries. Typically, one day a chap is a competent line pilot and the next he / she is sitting in an office with their name on the door, wondering what the heck they are supposed to be doing. Consequently, ill-briefed and ill-prepared they take the 'safe course' - and don't make decisions, or they make decisions that don't agree with the 'management party line' and get a severe 'career interview'. Either way, they may well become ineffective managers and not necessarily due to latent incompetence. Either way the industry suffers.
Many CEO's (Accountable Managers) have little or no understanding of the minutae of the line operation. I replaced someone as a JAA Accountable Manager, who had absolutely no idea of what his responsibilities were. Although I was surprised I quickly realised this is not an unusual situation.
Summary of the above: many airline managers may be well-intentioned but desperately ill-prepared for the job.
We cannot avoid the 'commercial expediency' that pervades our industry, any more than any other. The mindless, and unsustainable, pursuit of constantly improved quarterly returns (ie; profits) puts CEO's in untenable positions and the stress is passed down the line to all management and supervisory positions, and results in 'extraneous' expenses, such as training, safety, etc, being pared back. The result is an operation that ostensibly meets all regulatory requirements but has nothing in reserve. Assumptions are made that all is well until something goes wrong. Concerns expressed by the pilot group are often seen as a nuisance that can be ignored. We all keep our fingers crossed that there won't be an accident or even a serious incident though often we feel as though we are living on borrowed time.
From time to time the industry becomes heavily involved with a trend that warrants attention. For many years this was Controlled Flight into Terrain (CFIT); now it is Loss of Control in Flight (LOC-I). LOC-I is now the largest single cause of accidents. having replaced CFIT by a significant margin. I have recently been involved in some interesting exchanges on the subject and offer my most recent thoughts for consideration and comment. They are presented slightly tongue-in-cheek, but I think you will get the gist of what I am trying to say.
"Thanks for this. Funnily enough I have just been reading the article in Flight International on the proposed (expected?) training for 'upset flight', LOC, LOC-I, and all the other myriad definitions it has. I am also wading through a document on the same subject. I am sure it is all well-intentioned, but there is very little being said about what, to my mind, is the principal cause of this situation - overreliance on automation to the exclusion of handling practice.
Loss of control is not like Swine Fever. It hasn't suddenly mysteriously blossomed somewhere then spread like wildfire through the pilot ranks. It has, instead, insidiously grown to be the major factor in aircraft accidents due to diminishing professional standards amongst pilots.
Do I mean that we have all suddenly become a bunch of glue-sniffing, soap-opera watching, layabouts more interested in a perceived glamorous lifestyle 'down route' than serious attention to what is an extremely demanding - though rewarding - profession?
No, but what I do mean is that we have allowed ourselves to be led by the nose by accountants and aircraft manufacturers to the extent that we no longer fly the aircraft: we have delegated what used to be the fun bit to the automatics.
This didn't start yesterday. It started with the Airbus and 'Next Gen' Boeings with their marketing emphasis on 'ease of operation' with little or no human intervention.
("Frankly, Monsieur Airline CEO, we could teach ze monkey to fly zis plane").
As the 'older generation' pilots, with their years of handling lesser technology aircraft chose when and whether to engage the automatics with little or no fear of the consequences, others, with minimum experience - and, in some cases, rank unsuitability for the job - were coerced by their managers to make maximum use of the magenta line, LNAV/VNAV, coupled approaches, etc, etc.
("You see, Monsieur, all ze peelot 'as to do is taxi in and taxi out, and we already 'ave ze fix for zat in the future").
Eventually, with rapid expansion in the industry, the hoary old guy in the left seat was often replaced with a spotty-faced youth with little experience but a fascination with wiggly amps and computers. He did really well until the automatics played up and he and his sidekick had to figure out - quickly - what all the waggly bits on the wing and tail were for, and how they reacted when the stick was moved.
In my humble opinion the answer does not merely lie with investing squillions of dollars on more technology and more simulator time and more expense and more procedures to learn, but enforcing - and reinforcing - training of the basics to ensure familiarity with the characteristics of the aircraft, THROUGHOUT THE FLIGHT ENVELOPE.
"Hey, Guys, you can actually fly the aircraft MANUALLY. I know it is a strange concept these days, but it still works the way the Wright Brothers envisioned. You don't automatically die if the autopilot disengages in the cruise. It is fun to hand fly the aircraft in the climb, as well as the descent, and there is nothing, absolutely nothing, quite as satisfying as doing a visual approach on a nice sunny day"
I could on for hours on this subject, and I am about to put pen to paper. Although I agree that more and better simulation can help, I also think we could do more to avoid some of the bone-headed decisions that some of our brethren make / made / will make in the future".
GW
What an interesting and thought-provoking thread this is turning out to be. Hopefully, we can continue to attract more contributors and thus more good ideas.
I would like to take up on a couple of points before digressing slightly.
'Management' comes in for a lot of stick, and much of it is justified. PJ alluded to a typical CEO having little or no understanding of the intricacies of an SMS and called into question the validity of MBA's standing in our industry. Both very valid points. However, airline managers - in many cases - are not carefully nurtured as they are in many other industries. Typically, one day a chap is a competent line pilot and the next he / she is sitting in an office with their name on the door, wondering what the heck they are supposed to be doing. Consequently, ill-briefed and ill-prepared they take the 'safe course' - and don't make decisions, or they make decisions that don't agree with the 'management party line' and get a severe 'career interview'. Either way, they may well become ineffective managers and not necessarily due to latent incompetence. Either way the industry suffers.
Many CEO's (Accountable Managers) have little or no understanding of the minutae of the line operation. I replaced someone as a JAA Accountable Manager, who had absolutely no idea of what his responsibilities were. Although I was surprised I quickly realised this is not an unusual situation.
Summary of the above: many airline managers may be well-intentioned but desperately ill-prepared for the job.
We cannot avoid the 'commercial expediency' that pervades our industry, any more than any other. The mindless, and unsustainable, pursuit of constantly improved quarterly returns (ie; profits) puts CEO's in untenable positions and the stress is passed down the line to all management and supervisory positions, and results in 'extraneous' expenses, such as training, safety, etc, being pared back. The result is an operation that ostensibly meets all regulatory requirements but has nothing in reserve. Assumptions are made that all is well until something goes wrong. Concerns expressed by the pilot group are often seen as a nuisance that can be ignored. We all keep our fingers crossed that there won't be an accident or even a serious incident though often we feel as though we are living on borrowed time.
From time to time the industry becomes heavily involved with a trend that warrants attention. For many years this was Controlled Flight into Terrain (CFIT); now it is Loss of Control in Flight (LOC-I). LOC-I is now the largest single cause of accidents. having replaced CFIT by a significant margin. I have recently been involved in some interesting exchanges on the subject and offer my most recent thoughts for consideration and comment. They are presented slightly tongue-in-cheek, but I think you will get the gist of what I am trying to say.
"Thanks for this. Funnily enough I have just been reading the article in Flight International on the proposed (expected?) training for 'upset flight', LOC, LOC-I, and all the other myriad definitions it has. I am also wading through a document on the same subject. I am sure it is all well-intentioned, but there is very little being said about what, to my mind, is the principal cause of this situation - overreliance on automation to the exclusion of handling practice.
Loss of control is not like Swine Fever. It hasn't suddenly mysteriously blossomed somewhere then spread like wildfire through the pilot ranks. It has, instead, insidiously grown to be the major factor in aircraft accidents due to diminishing professional standards amongst pilots.
Do I mean that we have all suddenly become a bunch of glue-sniffing, soap-opera watching, layabouts more interested in a perceived glamorous lifestyle 'down route' than serious attention to what is an extremely demanding - though rewarding - profession?
No, but what I do mean is that we have allowed ourselves to be led by the nose by accountants and aircraft manufacturers to the extent that we no longer fly the aircraft: we have delegated what used to be the fun bit to the automatics.
This didn't start yesterday. It started with the Airbus and 'Next Gen' Boeings with their marketing emphasis on 'ease of operation' with little or no human intervention.
("Frankly, Monsieur Airline CEO, we could teach ze monkey to fly zis plane").
As the 'older generation' pilots, with their years of handling lesser technology aircraft chose when and whether to engage the automatics with little or no fear of the consequences, others, with minimum experience - and, in some cases, rank unsuitability for the job - were coerced by their managers to make maximum use of the magenta line, LNAV/VNAV, coupled approaches, etc, etc.
("You see, Monsieur, all ze peelot 'as to do is taxi in and taxi out, and we already 'ave ze fix for zat in the future").
Eventually, with rapid expansion in the industry, the hoary old guy in the left seat was often replaced with a spotty-faced youth with little experience but a fascination with wiggly amps and computers. He did really well until the automatics played up and he and his sidekick had to figure out - quickly - what all the waggly bits on the wing and tail were for, and how they reacted when the stick was moved.
In my humble opinion the answer does not merely lie with investing squillions of dollars on more technology and more simulator time and more expense and more procedures to learn, but enforcing - and reinforcing - training of the basics to ensure familiarity with the characteristics of the aircraft, THROUGHOUT THE FLIGHT ENVELOPE.
"Hey, Guys, you can actually fly the aircraft MANUALLY. I know it is a strange concept these days, but it still works the way the Wright Brothers envisioned. You don't automatically die if the autopilot disengages in the cruise. It is fun to hand fly the aircraft in the climb, as well as the descent, and there is nothing, absolutely nothing, quite as satisfying as doing a visual approach on a nice sunny day"
I could on for hours on this subject, and I am about to put pen to paper. Although I agree that more and better simulation can help, I also think we could do more to avoid some of the bone-headed decisions that some of our brethren make / made / will make in the future".
GW
Well, I hand fly every approach Autothrottles off disconnecting everything by 1500' at the latest.
This is unless weather demands a monitored approach , full Autoland, or if I feel excessively fatigued.
Several reasons, the currency 'keeping your hand in' is absolutely vital, I find it simpler to hand fly, but most of all I enjoy it enormously, the challenge, the satisfaction of doing a good job, is for most of us, I think, the reason why we became Pilots in the first place.
There is far too much dependence on Automation out there, I find the reasons behind the recent THY crash to be incomprehensible.
This is unless weather demands a monitored approach , full Autoland, or if I feel excessively fatigued.
Several reasons, the currency 'keeping your hand in' is absolutely vital, I find it simpler to hand fly, but most of all I enjoy it enormously, the challenge, the satisfaction of doing a good job, is for most of us, I think, the reason why we became Pilots in the first place.
There is far too much dependence on Automation out there, I find the reasons behind the recent THY crash to be incomprehensible.
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Cecil Lewis summed this thread up many years ago.
I have lurked around the good points on this interesting and thought provoking thread and suddenly realised that the whole thing was summed up by Cecil Lewis (RIP) in his book "Saggitariius Rising". I refer to his training of the Chinese and the many issues he encountered when trying to put together an airlline there post 1918 before he became disillusioned and he returned to set up the BBC.
I'd put money on any Chinese pilot today. Time and tide. I worry about the culture here these days. Where is "here"? Britain unfortunately.
We all share the same human traits. No nation, race, people, is necessarily culturally better equipped to produce pilots. It just takes time, training and patience.
I'd put money on any Chinese pilot today. Time and tide. I worry about the culture here these days. Where is "here"? Britain unfortunately.
We all share the same human traits. No nation, race, people, is necessarily culturally better equipped to produce pilots. It just takes time, training and patience.
Well as long as the floor is still open for discussion, I'll weigh in with some different perspectives.
It's not useful to highlight the airline CEO or even the bean counters when discussing safety. They have their jobs to do and it isn't to lead or even to promote regarding safety. Their best roll is a supporting roll. The promotion and leading of safety has to be done by people who understand the differences between risk and safety.
An organization needs the equivalent of an ombudsman who tracks items that identify risk, unsafe practices and has a process that brings to bear corrective actions that manages identified risk items to a level of safety commensurate with the rest of the industry. Sure it's nice to be risk free or perfectly safe (in your own mind) but you'll only dream of this. But woe to the organization that allows itself to be perceived as less safe than others.
So look around you, who in your organization is the person responsible for identifying risky practices and promoting actons to correct these? The bigger the organization the bigger the staff, but it sure ain't the CEO or a bean counter staff. I've come to believe that it really is some of you on this board. But I don't like to hear about inpediments in this process that have us pointing fingers away from ourselves with the idea that it's somebody else job and they just don't understand what they are doing.
It's not useful to highlight the airline CEO or even the bean counters when discussing safety. They have their jobs to do and it isn't to lead or even to promote regarding safety. Their best roll is a supporting roll. The promotion and leading of safety has to be done by people who understand the differences between risk and safety.
An organization needs the equivalent of an ombudsman who tracks items that identify risk, unsafe practices and has a process that brings to bear corrective actions that manages identified risk items to a level of safety commensurate with the rest of the industry. Sure it's nice to be risk free or perfectly safe (in your own mind) but you'll only dream of this. But woe to the organization that allows itself to be perceived as less safe than others.
So look around you, who in your organization is the person responsible for identifying risky practices and promoting actons to correct these? The bigger the organization the bigger the staff, but it sure ain't the CEO or a bean counter staff. I've come to believe that it really is some of you on this board. But I don't like to hear about inpediments in this process that have us pointing fingers away from ourselves with the idea that it's somebody else job and they just don't understand what they are doing.