"To err is human": differing attitudes to mistakes in EK and Turkish accidents
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Sorry, but the THY accident surely is lack of awareness or monitoring, otherwise how did the autothrottle shut off the power, resulting in a speed loss of over 40kt that not one of the 4 on the flightdeck noticed.
Maybe 'what is is doing now?' is correct; a category of fogetfullness that is never repeated, as all flight deck were killed. A sad day, but it would have been sadder still if there were no survivors. dbee
Maybe 'what is is doing now?' is correct; a category of fogetfullness that is never repeated, as all flight deck were killed. A sad day, but it would have been sadder still if there were no survivors. dbee
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I see your point lomapaseo, but I can't help thinking that this is 'ideal world' stuff & doesn't have a lot of bearing on what actually happens out there in the real world.
The people who understand the differences between risk & safety & the "ombudsman" you mentioned are already there as the safety manager & his/her department, supported by line pilot reporting. The safety department is there because the various regulatory authorities mandate it. The problem, as has been mentioned earlier, is that these people are generally kept out of the inner circle. Flight ops management generally do little to support them & the non-flying types don't understand why they are required anyway. Coupled with the fact that they generally have no power to effect change & rely on the good will of the decision makers to get any recomendations implemented, they are often only there to pay lip service to the regulatory requirement. The other problem is that many reports from the line are seen by senior management as a grab by line pilots for better conditions under the guise of safety.
The only way to have a really effective safety department is to have total buy in at the most senior level of the executive management. If the CEO has a safety manager he/she totally trusts & has them reporting directly to him/her, safety recomendations stand a chance of being implemented. But because most CEO's these days are not the aviation people of years gone by, they do not understand the importance of this. CEO's these days jump from one position to another & from one industry to another quite regularly. Their skills are seen as readily transferable & not industry specific now. This generally works out Ok in most industries, but the quite unique nature of the aviation business seems to be no longer understood.
Good or bad pilots, training, experience all mean nothing to the modern CEO or even senior management. The only requirement in their minds is a licenced pilot. Modern management has been influenced by the manufacturers that "any piloy can fly this aeroplane" &, due to their lack of aviation background, they believe it. Greywings summed it up perfectly!
The problem is that everything costs. Finding good pilots & getting rid of bad ones costs (before you all get stuck into me, I'm talking about the very few who have no business on a flight deck), training costs & even experience costs. And of course, safety costs. When you have a bunch of accountants in middle management, all with the ear of a cost aware CEO who is trying to keep the shareholders happy, cost is a dirty word! Someone once said that accountants know the cost of everything & the value of nothing. Perhaps they were right.
So the flight ops departments have to come up with ways to enable any pilot fly their aircraft & still keep cost under control. The solution is often to have what they consider strong SOP's & rigid adherance to them. An often inflexable automation policy also helps. This works fine while all is going to plan, but often falls way short when things start going wrong. It also has the suble tendancy to de-skill pilots in many areas, including manipulation & decision making. I think that we are starting to see the long term effects of this with some of the recent incidents & accidents. When a very senior manager of a flight ops department in a large ME carrier states to a group of pilots in a meeting, "I do not believe that low morale is in any way related to flight safety", you can see how far that these people have bought into the SOP/automation myth!
I believe that this all started with deregulation & low cost carriers, but I am sure that many will have another take on the reasons for the problems the industry faces today. However, we would all do well to listen to Greywings & PJ2. They certainly know what they are talking about in my humble opinion.
The people who understand the differences between risk & safety & the "ombudsman" you mentioned are already there as the safety manager & his/her department, supported by line pilot reporting. The safety department is there because the various regulatory authorities mandate it. The problem, as has been mentioned earlier, is that these people are generally kept out of the inner circle. Flight ops management generally do little to support them & the non-flying types don't understand why they are required anyway. Coupled with the fact that they generally have no power to effect change & rely on the good will of the decision makers to get any recomendations implemented, they are often only there to pay lip service to the regulatory requirement. The other problem is that many reports from the line are seen by senior management as a grab by line pilots for better conditions under the guise of safety.
The only way to have a really effective safety department is to have total buy in at the most senior level of the executive management. If the CEO has a safety manager he/she totally trusts & has them reporting directly to him/her, safety recomendations stand a chance of being implemented. But because most CEO's these days are not the aviation people of years gone by, they do not understand the importance of this. CEO's these days jump from one position to another & from one industry to another quite regularly. Their skills are seen as readily transferable & not industry specific now. This generally works out Ok in most industries, but the quite unique nature of the aviation business seems to be no longer understood.
Good or bad pilots, training, experience all mean nothing to the modern CEO or even senior management. The only requirement in their minds is a licenced pilot. Modern management has been influenced by the manufacturers that "any piloy can fly this aeroplane" &, due to their lack of aviation background, they believe it. Greywings summed it up perfectly!
The problem is that everything costs. Finding good pilots & getting rid of bad ones costs (before you all get stuck into me, I'm talking about the very few who have no business on a flight deck), training costs & even experience costs. And of course, safety costs. When you have a bunch of accountants in middle management, all with the ear of a cost aware CEO who is trying to keep the shareholders happy, cost is a dirty word! Someone once said that accountants know the cost of everything & the value of nothing. Perhaps they were right.
So the flight ops departments have to come up with ways to enable any pilot fly their aircraft & still keep cost under control. The solution is often to have what they consider strong SOP's & rigid adherance to them. An often inflexable automation policy also helps. This works fine while all is going to plan, but often falls way short when things start going wrong. It also has the suble tendancy to de-skill pilots in many areas, including manipulation & decision making. I think that we are starting to see the long term effects of this with some of the recent incidents & accidents. When a very senior manager of a flight ops department in a large ME carrier states to a group of pilots in a meeting, "I do not believe that low morale is in any way related to flight safety", you can see how far that these people have bought into the SOP/automation myth!
I believe that this all started with deregulation & low cost carriers, but I am sure that many will have another take on the reasons for the problems the industry faces today. However, we would all do well to listen to Greywings & PJ2. They certainly know what they are talking about in my humble opinion.
GW;
Precisely.
With a few notable exceptions, (native ability/intelligence/experience) it was the same where I worked as well. Those that went into management were often very junior, intent on improving their working conditions by controlling what their "juniority" could not, or getting a promotion (bigger airplane or a left-seat job which their seniority would not permit outside line pilot seniority). That's not a cynical opinion nor is it intended to slam management personnel. That's what happened, routinely - it's how middle management was (and is) usually staffed. The experienced ones flew the line and kept their head down because they knew the work was thankless with little support from above, the politics were distracting and sometimes risky to one's advancement, and the monetary benefits minimal.
All this said, your point is exactly on the mark - by virtue of the absence of formal training, mentoring or internship programs for such a purpose, most airline management below the senior and executive levels are ill-prepared for the work and do indeed make very conservative decisions, (I have written about this problem before in relation to SMS and the need for courageous but expensive safety decisions and will not repeat comments here), but are, in almost every case, extremely well-intentioned.
Again, the Challenger-Columbia accidents and the dynamics at NASA in both cases are highly instructive and I would commend anyone interested/fascinated with these dynamics to find and read the following texts for a solid, far better reading than we can offer here on a complex, often-ignored subject: the factors, characteristics and issues here being discussed. The books are:
The Challenger Launch Decision, Diane Vaughan, Chicago Press;
Organization at the Limit, Moshe Farjoun, William Starbuck, Blackwell
As mentioned before, Sidney Dekker's books are of immense value in putting flesh to the points raised here. Just Culture and The Field Guide to Understanding Human Factors are both well worth the investment in careful reading.
In particular GW, your point regarding the well-intentioned manager is made a number of times in the first two works cited above, the point being of course, that "amoral calculation" (Vaughan, 1996) is not a factor in accidents and instead "the best of intentions" is cited along with the valuable notion, the "normalization of deviance", a human factor with which we are all familiar in our daily lives but which, because we are so accustomed to such justifications for change, is invisible in high-risk environments, a factor which is exacerbated by the aforementioned lack of specialized, focused training for flight operations management personnel.
lomapaseo;
Re,
Hm, I think you will find that most safety literature will disagree with your assessment that the role of executive management is not to lead and/or promote safety within the organization they are responsible for. To be sure, (and I have been careful to qualify this thought a number of times), it is not necessary that they be safety specialists or even knowledgeable about the intracacies of flight safety work; I even agree that their main responsibility is indeed to ensure the commercial health of the enterprise - obviously safety is immaterial to a grounded, bankrupt carrier.
But if the organizations managers/employees are receiving the message straight from the top that "safety doesn't count when commercial or scheduling pressures are high, employee productivity is always a concern or maintenance "delays" keep airplanes in the hangar for "too long", (I'm exaggerating I know - such "messages" are almost always far more subtle but again, I'm trying to keep posts to a reasonable length and not succeeding very well), you may be certain that those messages will be acted upon by well-intentioned managers, not because they are apple-polishing but because, "that is the way things are done here".
If however, an organization has a healthy safety culture, not "led" but "engendered" within the organization from the very top, then managers know that they will be supported when a critical SMS-driven decision runs counter to the organization's commercial interests and priorities. One thing is a bureaucratic and psychological certainty within the social network and structure of an organization - an employee will invariably listen to the message delivered by his/her boss than by a trainer or safety specialist.
That is what is meant by CEO's/beancounters etc "understanding safety". If an executive only knows, say, marketing, then all problems and solutions are seen within a marketing "discourse" and may be wholly inappropriate in terms of support for sufficient resources. The role of the CEO/President etc, cannot be underestimated but it should not be confused with the need for "subject-matter-expertise". One can lead, motivate and support quite effectively even if one is not an expert in one or another fields. In fact, that is the very definition of "manager". This is what is meant by holding the CEO accountable for leadership in safety.
I would like to address your second point,
If I might respectfully offer, the "ombudsman" you describe is the organization's flight safety department and the tracking and risk assessment activities are the various flight safety programs created, put in place and properly, effectively resourced and then actually employed and otherwise hearkened to by the organization's flight operations department. The establishing of such programs and the appropriate resourcing of same is not the responsibility of safety people - it is the CEO's/beancounters' responsibility to ensure such programs are created and sufficiently resourced. That has been my point all along, perhaps poorly expressed at times!
But examination of the point you make regarding how such an "ombudsman" would work within an organization in terms of authority and independance of voice must be taken further.
The assumption is, the safety people in place to risk and trend assess will actually be listened to, their and their safety programs' input taken seriously, and their authority to interdict in a number of established and accepted ways. This is a somewhat idealistic expectation and does not always obtain. The notions of "box-ticking" and "pushing rope" express real manager and employee frustrations with an absence of what seems should be an obvious involvement. Such engagement simply cannot be taken as given. Both the Challenger and Columbia accident reports indicate this as do the more enlightened and broadly-conceived reports on accidents including Moshansky's Report on the Air Ontario Dryden accident. Ignoring flight data was cited as a causal factor at, of all carriers, QANTAS, in their overrun accident at Bangkok. I have witnessed flight data which indicated a very serious airframe exceedance sent to all relevant departments including operations and maintenance but which was summarily ignored in favour of dispatching the aircraft. I can assure you, without details, that we were not silent but it took a significant intervention over a relatively long period of time to obtain appropriate action though all after the fact. So there is not an automatic relationship between any "ombudsman" to use your term and the operations people but the appearance and subsequent illusions of same may lead one to believe it so if not examined for what it is.
In fact, under a de-regulated SMS environment in Canada, the US and elsewhere, where SMS documentation and accreditation (IOSA, for example) are perhaps viewed by CEOs/beancounters as sufficiently acceptable measures and even sought after (the accreditation game), and which may be imbued perhaps greater importance than actually seeing/knowing what is going on within their organization, it is not unreasonable to observe, given a host of recent accidents the nature of which has not been seen before at least in such frequency, that we have a safety system at significant risk of further deterioration.
In pointing to pilots as responsible entities, I think you re-state a valuable factor which requires highlighting;- that it is "us" indeed and as well, who must maintain our guard. This is a systems approach, not a component approach. While management must always lead, (unions, employees, even the regulator, do not and cannot ultimately lead - effective leadership for a safety culture must always emanate straight from the top), employees and their respective representatives are not bystanders but integral contributors and, in many cases where priorities are seen to be imbalanced, responsible for intervention whether singular or structural. Flight crews are "at the coal face" and are in the best position to provide feedback. Pilot unions have a long history of flight safety involvement but, just as companies will place commercial priorities higher, unions often place industrial matters as higher priorities than the less sexy and "pedantic" safety agenda. While pilots and their representatives play a significant role in regulatory reform, aircraft and procedural design, procuring volunteers or arranging displacements from flying so that such work can be done is often problemmatic in terms of resources. So I think your point in this is well taken - we indeed have a large and unavoidable responsibility.
In the end however, the metaphor of "pushing rope" is applicable. If the CEO doesn't want it or doesn't make it hurt if a certain tolerance for compromise in flight safety occurs or is established within the organization, there is little that pilots, unions, or even the regulator can do.
kind regards as always,
Oakape;
I have mentioned this here before but I heard it straight from a very senior Boeing manager involved in flight safety work that in his experience today's airline CEO's know little to nothing about flight safety or even the engineering/technical aspects of aviation or aircraft purchasing and thus are very difficult to communicate with or talk to concerning the matters raised in this thread, all of which have serious relevance for the organization of which one is CEO. It was for me, a disappointing confirmation of my own experience where I once worked and is, in my view, with other equally serious issues, near the heart of the presently-unfolding issues being discussed here.
PJ2
Summary of the above: many airline managers may be well-intentioned but desperately ill-prepared for the job.
With a few notable exceptions, (native ability/intelligence/experience) it was the same where I worked as well. Those that went into management were often very junior, intent on improving their working conditions by controlling what their "juniority" could not, or getting a promotion (bigger airplane or a left-seat job which their seniority would not permit outside line pilot seniority). That's not a cynical opinion nor is it intended to slam management personnel. That's what happened, routinely - it's how middle management was (and is) usually staffed. The experienced ones flew the line and kept their head down because they knew the work was thankless with little support from above, the politics were distracting and sometimes risky to one's advancement, and the monetary benefits minimal.
All this said, your point is exactly on the mark - by virtue of the absence of formal training, mentoring or internship programs for such a purpose, most airline management below the senior and executive levels are ill-prepared for the work and do indeed make very conservative decisions, (I have written about this problem before in relation to SMS and the need for courageous but expensive safety decisions and will not repeat comments here), but are, in almost every case, extremely well-intentioned.
Again, the Challenger-Columbia accidents and the dynamics at NASA in both cases are highly instructive and I would commend anyone interested/fascinated with these dynamics to find and read the following texts for a solid, far better reading than we can offer here on a complex, often-ignored subject: the factors, characteristics and issues here being discussed. The books are:
The Challenger Launch Decision, Diane Vaughan, Chicago Press;
Organization at the Limit, Moshe Farjoun, William Starbuck, Blackwell
As mentioned before, Sidney Dekker's books are of immense value in putting flesh to the points raised here. Just Culture and The Field Guide to Understanding Human Factors are both well worth the investment in careful reading.
In particular GW, your point regarding the well-intentioned manager is made a number of times in the first two works cited above, the point being of course, that "amoral calculation" (Vaughan, 1996) is not a factor in accidents and instead "the best of intentions" is cited along with the valuable notion, the "normalization of deviance", a human factor with which we are all familiar in our daily lives but which, because we are so accustomed to such justifications for change, is invisible in high-risk environments, a factor which is exacerbated by the aforementioned lack of specialized, focused training for flight operations management personnel.
lomapaseo;
Re,
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.
But if the organizations managers/employees are receiving the message straight from the top that "safety doesn't count when commercial or scheduling pressures are high, employee productivity is always a concern or maintenance "delays" keep airplanes in the hangar for "too long", (I'm exaggerating I know - such "messages" are almost always far more subtle but again, I'm trying to keep posts to a reasonable length and not succeeding very well), you may be certain that those messages will be acted upon by well-intentioned managers, not because they are apple-polishing but because, "that is the way things are done here".
If however, an organization has a healthy safety culture, not "led" but "engendered" within the organization from the very top, then managers know that they will be supported when a critical SMS-driven decision runs counter to the organization's commercial interests and priorities. One thing is a bureaucratic and psychological certainty within the social network and structure of an organization - an employee will invariably listen to the message delivered by his/her boss than by a trainer or safety specialist.
That is what is meant by CEO's/beancounters etc "understanding safety". If an executive only knows, say, marketing, then all problems and solutions are seen within a marketing "discourse" and may be wholly inappropriate in terms of support for sufficient resources. The role of the CEO/President etc, cannot be underestimated but it should not be confused with the need for "subject-matter-expertise". One can lead, motivate and support quite effectively even if one is not an expert in one or another fields. In fact, that is the very definition of "manager". This is what is meant by holding the CEO accountable for leadership in safety.
I would like to address your second point,
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.
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.
But examination of the point you make regarding how such an "ombudsman" would work within an organization in terms of authority and independance of voice must be taken further.
The assumption is, the safety people in place to risk and trend assess will actually be listened to, their and their safety programs' input taken seriously, and their authority to interdict in a number of established and accepted ways. This is a somewhat idealistic expectation and does not always obtain. The notions of "box-ticking" and "pushing rope" express real manager and employee frustrations with an absence of what seems should be an obvious involvement. Such engagement simply cannot be taken as given. Both the Challenger and Columbia accident reports indicate this as do the more enlightened and broadly-conceived reports on accidents including Moshansky's Report on the Air Ontario Dryden accident. Ignoring flight data was cited as a causal factor at, of all carriers, QANTAS, in their overrun accident at Bangkok. I have witnessed flight data which indicated a very serious airframe exceedance sent to all relevant departments including operations and maintenance but which was summarily ignored in favour of dispatching the aircraft. I can assure you, without details, that we were not silent but it took a significant intervention over a relatively long period of time to obtain appropriate action though all after the fact. So there is not an automatic relationship between any "ombudsman" to use your term and the operations people but the appearance and subsequent illusions of same may lead one to believe it so if not examined for what it is.
In fact, under a de-regulated SMS environment in Canada, the US and elsewhere, where SMS documentation and accreditation (IOSA, for example) are perhaps viewed by CEOs/beancounters as sufficiently acceptable measures and even sought after (the accreditation game), and which may be imbued perhaps greater importance than actually seeing/knowing what is going on within their organization, it is not unreasonable to observe, given a host of recent accidents the nature of which has not been seen before at least in such frequency, that we have a safety system at significant risk of further deterioration.
In pointing to pilots as responsible entities, I think you re-state a valuable factor which requires highlighting;- that it is "us" indeed and as well, who must maintain our guard. This is a systems approach, not a component approach. While management must always lead, (unions, employees, even the regulator, do not and cannot ultimately lead - effective leadership for a safety culture must always emanate straight from the top), employees and their respective representatives are not bystanders but integral contributors and, in many cases where priorities are seen to be imbalanced, responsible for intervention whether singular or structural. Flight crews are "at the coal face" and are in the best position to provide feedback. Pilot unions have a long history of flight safety involvement but, just as companies will place commercial priorities higher, unions often place industrial matters as higher priorities than the less sexy and "pedantic" safety agenda. While pilots and their representatives play a significant role in regulatory reform, aircraft and procedural design, procuring volunteers or arranging displacements from flying so that such work can be done is often problemmatic in terms of resources. So I think your point in this is well taken - we indeed have a large and unavoidable responsibility.
In the end however, the metaphor of "pushing rope" is applicable. If the CEO doesn't want it or doesn't make it hurt if a certain tolerance for compromise in flight safety occurs or is established within the organization, there is little that pilots, unions, or even the regulator can do.
kind regards as always,
Oakape;
But because most CEO's these days are not the aviation people of years gone by, they do not understand the importance of this. CEO's these days jump from one position to another & from one industry to another quite regularly. Their skills are seen as readily transferable & not industry specific now. This generally works out Ok in most industries, but the quite unique nature of the aviation business seems to be no longer understood.
PJ2
Last edited by PJ2; 28th May 2009 at 19:52.
I guess PJ2 you will always out wordsmith me in your replies. Yes there is much that we can agree upon but of course in the end what is going to be done about our frustrations.
You continue to raise the specter of the ignorant CEO being a block.
I don't see it that way.
It's the job of the people wihin the organization charged with safety (assessments, and corrective actions) to perform the task while at the same time being allowed to do so. Yes, I have seen ignorance from above but an awakening from the safety professional within the organization is what is needed and almost always works.
You even mentioned a highly placed safety executive from a manufacturer agreeing with you about the shortcomings of airline's CEO, amen to that. But I will add that in such cases where safety was not being met these same manufacturer's safety orgainizations have met with the airlines of concern and brought about immediate recognition and correction of the problems. I guess it was a shame that the airlines didn't see the writing on the wall as well, but in the end they did recognize that they indeed had a problem when an safety expert laid the data in front of them.
So I'm not willing to throw this problem over the fence towards a CEO or whomever. It truly is our problem to communicate effectively to anybody standing in the way of safety to the standards of today's "best practices"
You continue to raise the specter of the ignorant CEO being a block.
I don't see it that way.
It's the job of the people wihin the organization charged with safety (assessments, and corrective actions) to perform the task while at the same time being allowed to do so. Yes, I have seen ignorance from above but an awakening from the safety professional within the organization is what is needed and almost always works.
You even mentioned a highly placed safety executive from a manufacturer agreeing with you about the shortcomings of airline's CEO, amen to that. But I will add that in such cases where safety was not being met these same manufacturer's safety orgainizations have met with the airlines of concern and brought about immediate recognition and correction of the problems. I guess it was a shame that the airlines didn't see the writing on the wall as well, but in the end they did recognize that they indeed had a problem when an safety expert laid the data in front of them.
So I'm not willing to throw this problem over the fence towards a CEO or whomever. It truly is our problem to communicate effectively to anybody standing in the way of safety to the standards of today's "best practices"
lomapaseo;
I never thought of it either as "wordsmithing" or a competition in who expresses ideas better. It is just the way I write.
Most definitely not in my experience. The number of times we have presented very serious incidents and one or two near-accidents to both senior AND in one case, the CEO and the full executive made no difference whatsoever. They simply did not "see", nor did they comprehend what the airplane had just done in any of the cases we presented and no one from Ops spoke up in support of the program. It was extremely disheartening and in my view, foreboding but there it was.
I am afraid your expectations regarding the ability of earnest safety people to do this work alone "in spite of" an unsupportive or non-engaged CEO are very much in error. The attitude expressed was, we're doing fine thank you. The data said otherwise but went nowhere.
Yes, we have a common problem and it is why I continue to write about it here and elsewhere so that others who experience this kind of management diffidence and over-confidence can know that they are not crazy but that it happens elsewhere in very large organizations. The issue is indeed driven from the top down and in many organizations only changes after an accident. It is this kind of disastrous intervention which is clearly to be avoided.
I don't wish to concentrate on narrow circumstances other than to illustrate what I believe others are also up against and why. One way or another, aviation provides it's lessons. The CEO is, prima facie, the leader and is accountable to the airlines' passengers, employees and shareholders. No flight safety group can function otherwise and would be, at best, a sham and at worst, a legal liability. I am afraid we'll have to agree to disagree and permit the thread to hopefully take the broader course.
best,
PJ2
I never thought of it either as "wordsmithing" or a competition in who expresses ideas better. It is just the way I write.
but an awakening from the safety professional within the organization is what is needed and almost always works.
I am afraid your expectations regarding the ability of earnest safety people to do this work alone "in spite of" an unsupportive or non-engaged CEO are very much in error. The attitude expressed was, we're doing fine thank you. The data said otherwise but went nowhere.
Yes, we have a common problem and it is why I continue to write about it here and elsewhere so that others who experience this kind of management diffidence and over-confidence can know that they are not crazy but that it happens elsewhere in very large organizations. The issue is indeed driven from the top down and in many organizations only changes after an accident. It is this kind of disastrous intervention which is clearly to be avoided.
I don't wish to concentrate on narrow circumstances other than to illustrate what I believe others are also up against and why. One way or another, aviation provides it's lessons. The CEO is, prima facie, the leader and is accountable to the airlines' passengers, employees and shareholders. No flight safety group can function otherwise and would be, at best, a sham and at worst, a legal liability. I am afraid we'll have to agree to disagree and permit the thread to hopefully take the broader course.
best,
PJ2
I am afraid your expectations regarding the ability of earnest safety people to do this work alone "in spite of" an unsupportive or non-engaged CEO are very much in error. The attitude expressed was, we're doing fine thank you. The data said otherwise but went nowhere.
Perhaps it lies in communications
I've never had a problem in painting a bullseye around the safety problem at hand (data data data, history and best practices etc. etc.). Once the bullseye has been illuminated everybody in the room does their best to get out of its aim. If they can't counter it with data and illustrative arguments then they at least become supportive of somebody who can make it go away.
One thing becomes clear early on.... as a presenter of the data I am not going away so the problem remains to be solved and not swept underneath a rug.
You are correct that the discussion we are having here is not between you and I. It is a discussion about where does the problem lie and who will fix it. I care not for those that throw it away as not there problem as many of the posters tend to do by fixing blame after an accident.
So yes the dicsussion may continue with others as well.
You are correct that the discussion we are having here is not between you and I. It is a discussion about where does the problem lie and who will fix it. I care not for those that throw it away as not there problem as many of the posters tend to do by fixing blame after an accident.
