Are we facing a safety issue?
mercurydancer;
I concur wholeheartedly with all you say regarding what is essential and not merely a privilege and I suspect even airline managers would agree with this notion and so too, I expect, would the regulator.
However, in your post you are talking about "should". The reality is substantially different and I see no dynamics (short of the kind of event which occurred in Canada and created the Moshansky Inquiry), that the industry in North America anyway, is about to change.
With profit margins as thin as ever, a recession on in most western countries except Canada and Australia and fuel prices at US$75/barrel and climbing, and unrealistic investor time frames and expectations keeping down share prices, the freedom to long-term plan, or provide "career development strategies" for pilots simply does not exist and, given industrial matters alone, would be next to impossible to establish.
I hope I understand what you mean here and please help me if I have misperceived. If I have understood your notion, I have to state that there is no such thing as a "measured career pathway" in this industry today or even when I was flying. There is no long-term structure for air crew development, and what's more, no manager is ever going to even broach the notion because it will go nowhere in today's operational environment.
While training, standards and checking, pay and benefits are, to varying degrees of robustness and success, all part of the mix in this industry as it has unfolded over the last thirty years, airlines today want "98.6" in the cockpit seats; only then do they deal with these other issues. The Colgan accident at Buffalo and the Comair accident at Lexington for two examples, highlighted what I and many in the industry have known and have been writing about for years - that the industry is just getting by in these initiatives and responsibilities. With an increasingly absent regulator which has, via "SMS" (Safety Management Systems) downloaded flight safety responsibilities in terms of self-regulation and self-auditing onto the airlines, the opportunity to do even less has opened up. Airlines are always searching for ways to reduce costs - a legitimate business strategy, providing there are both programs and metrics in place to advise when management has cut too close to the bone. Such programs are generally unpopular with cash-strapped managements however, and, with an absentee regulator, can "safely" be ignored until/unless something serious happens, (in which case we are back to kicking tin).
Please know that I fully understand that these notions and this writing are very black-and-white, polarizing ideas rather than teasing out the subtleties and exceptions, the vast number of unsung successes and making clear that the industry is still extremely safe in comparison with other modes of transportation. Highlighting weaknesses in a high-risk system is what safety people do all the time. My views, while perhaps to some seem like bleeding on and on here and in other threads as to signals and causes, are by no means alone. These are long-term trends that are unfolding, that will end in an increasing accident rate within our industry unless measures are taken to address the issues being raised. The FAA has actually responded in the US and for very good reason as illustrated in the serious maintenance violations discovered at Southwest Airlines, American Airlines and others.
I think it is naive to expect or believe that airlines would develop pilots at a "measured pace" and that career advancement is something that airlines actually care about. They don't - not one bit. If they could get an autoflight system that got rid of one of the two expensive resources in the cockpit, they would buy it in a heartbeat. Beyond a reluctant acknowledgement in cases where push comes to shove such as long-haul crew augmentation, they don't even care how fatigued their pilots are, a fact demonstrated by airlines' refusal to involve themselves more than they must to keep peace, in formal discussions on fatigue risk management approaches for domestic and overseas long-haul pilots alike.
The industry is at a turning point in its safety record. For various reasons expressed here and in other threads, (the constancy and lengths of posts for which I apologize), those who are coming into and managing this industry and who are far away from the coal-face, have little to no idea of how it got so safe and are taking for granted its spectacular safety record and the processes which brought about that record including a strong willingness to take a very close look at its ugly parts.
The dynamics of airline traffic growth in an increasingly de-regulated environment where regulatory oversight is concerned, versus the availability of experienced, "case-hardened" pilots who actually still want to work in this industry, have placed these two phenomena on a collision course and we are already seeing early results. That is the only point being made in all these words.
I know only too keenly that this isn't pleasant stuff for most to read. But it is the kind of stuff that made this industry as safe as it is. If, as lomapaseo expresses, others read these discussions and take away some doubts as to their own operation and find "new eyes" with which to view their operation's approach to safety, then this will have been worth the effort by all. This is anything but critical of the industry I love. While criticism is traditionally anything but popular and is usually seen as not being a "team player", (big mistake, in my view), to me, strong criticism is the highest form of loyalty. We need more than ever, an inquiry into how this industry is changing.
I've said more than enough. We will see where this goes.
Whilst air travel is not essential it is largely an inescapable part of modern life. SLF invest money and their lives in air transport. I imagine that I am not alone in thinking that I would want to pay my fares to a company with both reliable aircraft and ground staff, (which as it is regulated is demonstrable to passengers) but also to a company who invest in the aircrew. A measured career pathway where the FD crew are taught appropriately, and gather substantial experience is not a privelege of select airlines but should be essential. Ive posted before about the trust that UK people had in BA and not without reason. To provide a long-term structure to air crew development is not optional it is essential and if MBA man thinks that it is not essential then he (or she) will see the company go the way of all things.
However, in your post you are talking about "should". The reality is substantially different and I see no dynamics (short of the kind of event which occurred in Canada and created the Moshansky Inquiry), that the industry in North America anyway, is about to change.
With profit margins as thin as ever, a recession on in most western countries except Canada and Australia and fuel prices at US$75/barrel and climbing, and unrealistic investor time frames and expectations keeping down share prices, the freedom to long-term plan, or provide "career development strategies" for pilots simply does not exist and, given industrial matters alone, would be next to impossible to establish.
I hope I understand what you mean here and please help me if I have misperceived. If I have understood your notion, I have to state that there is no such thing as a "measured career pathway" in this industry today or even when I was flying. There is no long-term structure for air crew development, and what's more, no manager is ever going to even broach the notion because it will go nowhere in today's operational environment.
While training, standards and checking, pay and benefits are, to varying degrees of robustness and success, all part of the mix in this industry as it has unfolded over the last thirty years, airlines today want "98.6" in the cockpit seats; only then do they deal with these other issues. The Colgan accident at Buffalo and the Comair accident at Lexington for two examples, highlighted what I and many in the industry have known and have been writing about for years - that the industry is just getting by in these initiatives and responsibilities. With an increasingly absent regulator which has, via "SMS" (Safety Management Systems) downloaded flight safety responsibilities in terms of self-regulation and self-auditing onto the airlines, the opportunity to do even less has opened up. Airlines are always searching for ways to reduce costs - a legitimate business strategy, providing there are both programs and metrics in place to advise when management has cut too close to the bone. Such programs are generally unpopular with cash-strapped managements however, and, with an absentee regulator, can "safely" be ignored until/unless something serious happens, (in which case we are back to kicking tin).
Please know that I fully understand that these notions and this writing are very black-and-white, polarizing ideas rather than teasing out the subtleties and exceptions, the vast number of unsung successes and making clear that the industry is still extremely safe in comparison with other modes of transportation. Highlighting weaknesses in a high-risk system is what safety people do all the time. My views, while perhaps to some seem like bleeding on and on here and in other threads as to signals and causes, are by no means alone. These are long-term trends that are unfolding, that will end in an increasing accident rate within our industry unless measures are taken to address the issues being raised. The FAA has actually responded in the US and for very good reason as illustrated in the serious maintenance violations discovered at Southwest Airlines, American Airlines and others.
I think it is naive to expect or believe that airlines would develop pilots at a "measured pace" and that career advancement is something that airlines actually care about. They don't - not one bit. If they could get an autoflight system that got rid of one of the two expensive resources in the cockpit, they would buy it in a heartbeat. Beyond a reluctant acknowledgement in cases where push comes to shove such as long-haul crew augmentation, they don't even care how fatigued their pilots are, a fact demonstrated by airlines' refusal to involve themselves more than they must to keep peace, in formal discussions on fatigue risk management approaches for domestic and overseas long-haul pilots alike.
The industry is at a turning point in its safety record. For various reasons expressed here and in other threads, (the constancy and lengths of posts for which I apologize), those who are coming into and managing this industry and who are far away from the coal-face, have little to no idea of how it got so safe and are taking for granted its spectacular safety record and the processes which brought about that record including a strong willingness to take a very close look at its ugly parts.
The dynamics of airline traffic growth in an increasingly de-regulated environment where regulatory oversight is concerned, versus the availability of experienced, "case-hardened" pilots who actually still want to work in this industry, have placed these two phenomena on a collision course and we are already seeing early results. That is the only point being made in all these words.
I know only too keenly that this isn't pleasant stuff for most to read. But it is the kind of stuff that made this industry as safe as it is. If, as lomapaseo expresses, others read these discussions and take away some doubts as to their own operation and find "new eyes" with which to view their operation's approach to safety, then this will have been worth the effort by all. This is anything but critical of the industry I love. While criticism is traditionally anything but popular and is usually seen as not being a "team player", (big mistake, in my view), to me, strong criticism is the highest form of loyalty. We need more than ever, an inquiry into how this industry is changing.
I've said more than enough. We will see where this goes.
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This is one of the most interesting and relevant threads here in a long time.
It seems to me that some of the LCC have relentlessly driven costs out of the business to such an extent that salaries and conditions and moral are so low that eventually a straw will come that will break the camels back. If that event is a serious safety incident than maybe the resulting spotlight will reflect on the Major way the industry model has changed over the past say ten years.
One of the other issues appears to be career management. People who jump from ship to ship and stay for a few years, drive more costs and conditions from their host companies , then take their bonuses and bugger of to repeat the trick elsewhere.
Maybe I am wrong and I well realise that we must continually change and adapt as economic and business models changes. BUT if pilots are holding down two jobs to make ends meet because of faceless managers who have driven costs to the bottom of the barrel, and those same pilots are involved in an accident, then we must ask ourselves when do we as a group of professionals say STOP.
In my view it's a little late for an industry wide reflection on the issues raised when there's a hole in the ground.
Comments or Maybe I am just letting of a bit of steam??
In answer to the threads question
Are we facing a safety issue? YES YES YES
It seems to me that some of the LCC have relentlessly driven costs out of the business to such an extent that salaries and conditions and moral are so low that eventually a straw will come that will break the camels back. If that event is a serious safety incident than maybe the resulting spotlight will reflect on the Major way the industry model has changed over the past say ten years.
One of the other issues appears to be career management. People who jump from ship to ship and stay for a few years, drive more costs and conditions from their host companies , then take their bonuses and bugger of to repeat the trick elsewhere.
Maybe I am wrong and I well realise that we must continually change and adapt as economic and business models changes. BUT if pilots are holding down two jobs to make ends meet because of faceless managers who have driven costs to the bottom of the barrel, and those same pilots are involved in an accident, then we must ask ourselves when do we as a group of professionals say STOP.
In my view it's a little late for an industry wide reflection on the issues raised when there's a hole in the ground.
Comments or Maybe I am just letting of a bit of steam??
In answer to the threads question
Are we facing a safety issue? YES YES YES
then we must ask ourselves when do we as a group of professionals say STOP.
.....something global would be good.
It sure is an attractive idea, but how do we go about saying "STOP" ?
.....something global would be good.
.....something global would be good.
It's time to get positive and not negative in the rhetoric
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PJ2
You havent misunderstood me at all.
Yes it is probable that I am naive in envisioning a structure for FD crew development. It is sad to hear that but I perfectly understand the reasons why it isnt so. For airlines not to invest in long term development of crew may be infleunced by short term financial priorities but it obstructs the longer term benefits of having FD crew who are very capable.
To use a phrase I dont particularly like, its my "blue sky thinking"
You havent misunderstood me at all.
Yes it is probable that I am naive in envisioning a structure for FD crew development. It is sad to hear that but I perfectly understand the reasons why it isnt so. For airlines not to invest in long term development of crew may be infleunced by short term financial priorities but it obstructs the longer term benefits of having FD crew who are very capable.
To use a phrase I dont particularly like, its my "blue sky thinking"
mercurydancer;
I have spent most of my career in naiveté. Flight safety work is mostly fighting rear-guard actions when in fact a career-development process would resolve many, though not all these issues. While I do not support the notion of the MCPL, like SMS it is not because the training or the concept itself is wrong but because I have no reason to believe that the MCPL will be handled properly by the airlines. Under the heading of "98.6" and the bare minimum the law requires in terms of experience levels, they will consider that anyone licensed to operate the aircraft is "competent".
That is where the "consolidation period" rule-making came from - airlines were pairing newbies with newbies (new on the airplane or new in the business) because they could. Wisdom never entered (or enters) the picture.
I know pilots who began flying transport aircraft at 250hrs and did just fine but that was because, at the time, the airline I worked for had a Second Officer's position and one "learned the ropes" in the back seat...so to speak.
Today, new hires, especially in the regionals, are "qualified" even though they may not have any experience in demanding circumstances.
Aviation is such that most of the time, nothing happens. But Charles Perrow's notions of the organizational accident and Jim Reason's now-familiar expression were meant to convey the notion that disparate circumstances randomly occur and sometimes very close together in time, and result in an otherwise-avoided accident.
I truly desire that aviation was as you blue-sky it! Perhaps a "College of Aviators" which sets standards, issues licences and examines candidates would resolve some of the issues. I think however, that both the medical and legal professions have much to teach anyone actually contemplating such an initiative...
I have spent most of my career in naiveté. Flight safety work is mostly fighting rear-guard actions when in fact a career-development process would resolve many, though not all these issues. While I do not support the notion of the MCPL, like SMS it is not because the training or the concept itself is wrong but because I have no reason to believe that the MCPL will be handled properly by the airlines. Under the heading of "98.6" and the bare minimum the law requires in terms of experience levels, they will consider that anyone licensed to operate the aircraft is "competent".
That is where the "consolidation period" rule-making came from - airlines were pairing newbies with newbies (new on the airplane or new in the business) because they could. Wisdom never entered (or enters) the picture.
I know pilots who began flying transport aircraft at 250hrs and did just fine but that was because, at the time, the airline I worked for had a Second Officer's position and one "learned the ropes" in the back seat...so to speak.
Today, new hires, especially in the regionals, are "qualified" even though they may not have any experience in demanding circumstances.
Aviation is such that most of the time, nothing happens. But Charles Perrow's notions of the organizational accident and Jim Reason's now-familiar expression were meant to convey the notion that disparate circumstances randomly occur and sometimes very close together in time, and result in an otherwise-avoided accident.
I truly desire that aviation was as you blue-sky it! Perhaps a "College of Aviators" which sets standards, issues licences and examines candidates would resolve some of the issues. I think however, that both the medical and legal professions have much to teach anyone actually contemplating such an initiative...
exeng
Thanks for the clarity of suggesting at least one area that may need fixing. If others support this with the same clarity than at least that item however small (one airline/one country) may get some attention.
Thanks for the clarity of suggesting at least one area that may need fixing. If others support this with the same clarity than at least that item however small (one airline/one country) may get some attention.
Today, new hires, especially in the regionals, are "qualified" even though they may not have any experience in demanding circumstances.
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Hi PJ2
This is one of the reasons (not James) why I find this site so fascinating.
I'd like to coin the phrase "professional jealousy" - Healthcare incident investigation is really in its early stages of development. Our gold standard is aircraft accident investigation. You would be surprised how rudimentary some healthcare investigations are, and even the well documented ones with sensible actions to take often shrivel and die in the bureaucracy.
CRM is also a concept that isnt easy to translate to a healthcare setting but it is possible with a little thought. Even so applying the concept has huge benefits.
It sounds like there is a possibility for mutual exchange of ideas and concepts here. Healthcare, in particular, nursing and medical career pathways, are very well regulated and have such things as competency training and experience measured in the number of procedures undertaken for instance. Qualification is rightly considered to be the first step, not a licence to be protected from inexperience. I'm not holding medicine up to be the best, just commenting that there appears to be some areas which we do better.
This is one of the reasons (not James) why I find this site so fascinating.
I'd like to coin the phrase "professional jealousy" - Healthcare incident investigation is really in its early stages of development. Our gold standard is aircraft accident investigation. You would be surprised how rudimentary some healthcare investigations are, and even the well documented ones with sensible actions to take often shrivel and die in the bureaucracy.
CRM is also a concept that isnt easy to translate to a healthcare setting but it is possible with a little thought. Even so applying the concept has huge benefits.
It sounds like there is a possibility for mutual exchange of ideas and concepts here. Healthcare, in particular, nursing and medical career pathways, are very well regulated and have such things as competency training and experience measured in the number of procedures undertaken for instance. Qualification is rightly considered to be the first step, not a licence to be protected from inexperience. I'm not holding medicine up to be the best, just commenting that there appears to be some areas which we do better.
I'm not holding medicine up to be the best, just commenting that there appears to be some areas which we do better
Honest question so I can put it to him at the next bbq, which areas are better? (please don't say fatigue management)
Kind Regards,
Framer
framer;
The notion of "safety" comes from knowing, vice not knowing.
"Knowing" comes from education, experience and intuition.
"Knowing" is not merely someone's opinion, especially if they happen to be in a position of power, (under a possible guise of "knowing").
Therefore, flight safety is always about "what", not "who".
If a junior Relief Pilot calls up front to correct an altimeter setting that would have taken the aircraft into the ground in IFR weather, that is about "what", not "who".
I flew with WWII and post WWII guys who treated any question/suggestion/exclamation with derision. One kept notes on each commander and how he liked dinner and what to say when transferring fuel. SOPs were a guide. That approach killed a lot of people.
Today, if someone doesn't speak up, they're in trouble.
The intervention is then sorted out and if real, adjustments are made and the situation resolved - right then and there.
It isn't about junior people "taking over" or trying to fly someone else's airplane. If it is, that's not CRM. The captain is still the commander and makes the final decision - it is NOT a democracy in the cockpit; it is an information-gathering place based upon "what", not "who".
Your test for any situation that feels like it is coming off the rails is that. If it is about "who", (ego, power, pouting, petulance and the other childhood emotions) then someone needs to intervene and get it back to "what".
It was a tall order when the change came twenty five years or so ago. We thought that many of the guys who needed such a change the most, never "got it" and retired not knowing.
That is how it is going to be for the medical profession. It will be different because of the nature of the work. If you sense the perceptions and the actions are about "someone", you're not doing CRM. If you keep only "what" in mind, you're safer.
The notion of "safety" comes from knowing, vice not knowing.
"Knowing" comes from education, experience and intuition.
"Knowing" is not merely someone's opinion, especially if they happen to be in a position of power, (under a possible guise of "knowing").
Therefore, flight safety is always about "what", not "who".
If a junior Relief Pilot calls up front to correct an altimeter setting that would have taken the aircraft into the ground in IFR weather, that is about "what", not "who".
I flew with WWII and post WWII guys who treated any question/suggestion/exclamation with derision. One kept notes on each commander and how he liked dinner and what to say when transferring fuel. SOPs were a guide. That approach killed a lot of people.
Today, if someone doesn't speak up, they're in trouble.
The intervention is then sorted out and if real, adjustments are made and the situation resolved - right then and there.
It isn't about junior people "taking over" or trying to fly someone else's airplane. If it is, that's not CRM. The captain is still the commander and makes the final decision - it is NOT a democracy in the cockpit; it is an information-gathering place based upon "what", not "who".
Your test for any situation that feels like it is coming off the rails is that. If it is about "who", (ego, power, pouting, petulance and the other childhood emotions) then someone needs to intervene and get it back to "what".
It was a tall order when the change came twenty five years or so ago. We thought that many of the guys who needed such a change the most, never "got it" and retired not knowing.
That is how it is going to be for the medical profession. It will be different because of the nature of the work. If you sense the perceptions and the actions are about "someone", you're not doing CRM. If you keep only "what" in mind, you're safer.
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The notion of "safety" comes from knowing, vice not knowing.
Otherwise safety is the state of being safe.
Knowing that the airplane in on fire doesn't make anybody safer.
Safety is also what the airline do or not, what the maintenance do or not, what is the weather condition...
There is so much to do to improve safety, aside from knowing.
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framer
The areas where we in medicine do well are continuing education/accreditation and competency training. This is the career structure I was dicussing with PJ2.
For CRM, we arent dacades behind aviation but certainly the CRM culture isnt developed in healthcare. I wish it was, but there are complicating factors. Even in an environment such as an operating room it is not a team doing one event, such as an aircraft in flight, its a number of teams with diferent values and allegiances who are in close proximity to each other. Its odd how it works out, a surgeon has total responsibility for his surgery but the anaesthetist has total responsibility for the patient and the nursing staff have total responsibility for the OR itself. The surgeon does not hold the same role as the captain of an aircraft by any means.
The areas where we in medicine do well are continuing education/accreditation and competency training. This is the career structure I was dicussing with PJ2.
For CRM, we arent dacades behind aviation but certainly the CRM culture isnt developed in healthcare. I wish it was, but there are complicating factors. Even in an environment such as an operating room it is not a team doing one event, such as an aircraft in flight, its a number of teams with diferent values and allegiances who are in close proximity to each other. Its odd how it works out, a surgeon has total responsibility for his surgery but the anaesthetist has total responsibility for the patient and the nursing staff have total responsibility for the OR itself. The surgeon does not hold the same role as the captain of an aircraft by any means.
Cheers mercury, I will bring up that side of it, the ongoing training etc.
Ta.
Why was that addressed to me? I never said anything about
...whats the go PJ? Regardless, I totally agree with what you said 
Ta.
framer;
The notion of "safety" comes from knowing, vice not knowing.
"Knowing" comes from education, experience and intuition.
"Knowing" is not merely someone's opinion, especially if they happen to be in a position of power, (under a possible guise of "knowing").
The notion of "safety" comes from knowing, vice not knowing.
"Knowing" comes from education, experience and intuition.
"Knowing" is not merely someone's opinion, especially if they happen to be in a position of power, (under a possible guise of "knowing").
junior people "taking over" or trying to fly someone else's airplane.
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The surgeon does not hold the same role as the captain of an aircraft by any means.
Time and again one hears of lack of respect for the captain's operational decisions and in turn this causes quiet resentment. One typical discussion occured where the captain asked the F/O to call ATC and request approval for a deviation 30 miles off track to avoid a large thunderstorm ahead seen on radar. The F/O disagreed with the captain's assessment and said he felt 30 miles was too much - and suggested 15 miles deviation was sufficient. This leaves the captain in a difficult situation.
His experience dictated a 30 mile deviation but he can either order in no uncertain terms the F/O do his bidding or he can compromise to keep the F/O happy and say OK make it 20 miles off track. Assertiveness is fine where there is a flight safety hazard but plain idiotic when it comes to deliberately making a point to score a point. And this type of exchange is a lot more common in some airlines than you would expect.
Presumably that would never happen in a surgical procedure where the surgeon is entirely on his own without someone monitoring his every decision and playing assertiveness because he can.
framer;
I apologize to you and to KAG for my complete lack of clarity in my response. I failed to make my meaning of the notion, "knowing", and therefore my point, clear, because I wrote the response in a hurry - always a mistake! Permit me a second shot at it:
The comments were in response to your post which I thought was very interesting and posed and interesting question. Nothing "directed at" you, just a response about CRM-type situations and how the medical profession could make progress in adopting, with substantial modification (for reasons given, ie, the surgeon is not the "captain", etc) such human-factors processes.
KAG, you're correct in saying "safety is the state of being safe", and that "knowing a wing is on fire" doesn't make things "safer". I can see where the confusion arose!
The key point I was attempting to make was, flight safety is about "what" not "who". It was trying to acknowledge that "knowing" (which is about 'what'), promoted understanding and therefore a safer operation, than "who", which is about someone's opinion, usually subtlely grounded in "authority" or "position", of how things should be run and which rarely produces understanding because it seeks obedience, not questions.
The difference is subtle. Obviously, knowledge and opinion may be the same in many circumstances but one is grounded in information available to the crew which someone is referencing, and the other appeals to a position of authority.
CRM is about information exchange, or "knowing", without regard to who was conveying the information. Dismissing information based upon who is conveying it is the exact opposite of what is intended by CRM.
Let me describe it in very black-and-white, simplistic terms, realizing that most issues and circumstances are far more subtle than this.
Previously, (pre-CRM type communications in cockpits), if a junior, (read "inexperienced") member of the crew said something, the crusty old captain might dismiss it and even think that the guy in the right seat was trying to take over his airplane.
F/O: "Captain, should we be descending to the procedure altitude out here?"
Captain: "He cleared us for the approach, didn't he?!"
F/O: "Yes, but we're thirty miles out..."
Captain: "We're cleared for the approach and that means we can descend!"
F/O: "But the chart... ,"
Captain: "I've been in and out of here hundreds of times. It's fine..."
In this admittedly-extreme example of a conversation, the decision-making process is about "who", (the captain vs the F/O), not "what", (should we be descending...?" The captain dismisses the F/O's comment subtlely using his position and claiming his experience with the airport which is about "who", to justify the descent instead of going further with the F/O's intervention and determing "what".
These circumstances applied at Tenerife, at Buga, (Colombia), Little Rock (Arkansas) and dozens of other accidents. CFIT accidents typically though not always, begin with poor CRM. The F/O on the KLM B747 questioned the captain's decision but he elected to take off, dismissing the intervention.
What I meant by my comment about "junior people flying the airplane" is, it is a serious misunderstanding of CRM on the part of both crew members to think that CRM is equivalent to "the F/O is taking over the airplane" if he or she raises questions about the operation. Questioning the captain is not the same as trying to fly his/her airplane. The captain is always in command by law, (one significant difference between aviation and medicine), and will always make the final decision unless it clearly threatens the safety of the flight. That does not relieve the other crew members of the duty and responsibility to speak up in all circumstances that require "knowing" about a situation.
Far more often however, it is not a "beligerant" captain but a captain who may have made a small error, didn't know something or assumed something and other crew members were either afraid to speak up out of embarrassment of possibly being wrong, or out of respect because the commander was "such a good pilot" or possibly out of fear because the commander was known to "bite off heads" if challenged. The dynamics are as varied as people are but the common thread is, "nobody said anything" and so there were two or three different understandings of the operational situation riding in the cockpit instead of one.
CRM came about because accident investigators realized through the CVR that a perfectly serviceable airplane was flown into the ground or into another aircraft killing a planeload of people because communications did not effectively establish a full, common understanding of the situation.
CRM doesn't end just with understanding.
One example of CRM in action was the United Airlines DC10 at Sioux City, where Denny Fitch, a dead-heading pilot sat behind the captain and First Officer and manipulated the throttles to fly the aircraft to the Sioux City airport. The captain handed control over to someone not even in his crew but who was "best qualified in the moment" to do the job; - "What", not "who". It was a brilliant command decision that saved 185 lives.
I hope this is a bit better explanation of what I was trying to say and that the simplifications are not otherwise patronizing your aviation knowledge. The subtleties of CRM and what CRM has evolved into now would take a much longer post but I hope the idea comes across reasonably well. I think medicine could benefit tremendously from such an approach, though, (as stated), modifications to suit the unique dynamics of medicine (vs aviation) would have to be made.
I apologize to you and to KAG for my complete lack of clarity in my response. I failed to make my meaning of the notion, "knowing", and therefore my point, clear, because I wrote the response in a hurry - always a mistake! Permit me a second shot at it:
The comments were in response to your post which I thought was very interesting and posed and interesting question. Nothing "directed at" you, just a response about CRM-type situations and how the medical profession could make progress in adopting, with substantial modification (for reasons given, ie, the surgeon is not the "captain", etc) such human-factors processes.
KAG, you're correct in saying "safety is the state of being safe", and that "knowing a wing is on fire" doesn't make things "safer". I can see where the confusion arose!
The key point I was attempting to make was, flight safety is about "what" not "who". It was trying to acknowledge that "knowing" (which is about 'what'), promoted understanding and therefore a safer operation, than "who", which is about someone's opinion, usually subtlely grounded in "authority" or "position", of how things should be run and which rarely produces understanding because it seeks obedience, not questions.
The difference is subtle. Obviously, knowledge and opinion may be the same in many circumstances but one is grounded in information available to the crew which someone is referencing, and the other appeals to a position of authority.
CRM is about information exchange, or "knowing", without regard to who was conveying the information. Dismissing information based upon who is conveying it is the exact opposite of what is intended by CRM.
Let me describe it in very black-and-white, simplistic terms, realizing that most issues and circumstances are far more subtle than this.
Previously, (pre-CRM type communications in cockpits), if a junior, (read "inexperienced") member of the crew said something, the crusty old captain might dismiss it and even think that the guy in the right seat was trying to take over his airplane.
F/O: "Captain, should we be descending to the procedure altitude out here?"
Captain: "He cleared us for the approach, didn't he?!"
F/O: "Yes, but we're thirty miles out..."
Captain: "We're cleared for the approach and that means we can descend!"
F/O: "But the chart... ,"
Captain: "I've been in and out of here hundreds of times. It's fine..."
In this admittedly-extreme example of a conversation, the decision-making process is about "who", (the captain vs the F/O), not "what", (should we be descending...?" The captain dismisses the F/O's comment subtlely using his position and claiming his experience with the airport which is about "who", to justify the descent instead of going further with the F/O's intervention and determing "what".
These circumstances applied at Tenerife, at Buga, (Colombia), Little Rock (Arkansas) and dozens of other accidents. CFIT accidents typically though not always, begin with poor CRM. The F/O on the KLM B747 questioned the captain's decision but he elected to take off, dismissing the intervention.
What I meant by my comment about "junior people flying the airplane" is, it is a serious misunderstanding of CRM on the part of both crew members to think that CRM is equivalent to "the F/O is taking over the airplane" if he or she raises questions about the operation. Questioning the captain is not the same as trying to fly his/her airplane. The captain is always in command by law, (one significant difference between aviation and medicine), and will always make the final decision unless it clearly threatens the safety of the flight. That does not relieve the other crew members of the duty and responsibility to speak up in all circumstances that require "knowing" about a situation.
Far more often however, it is not a "beligerant" captain but a captain who may have made a small error, didn't know something or assumed something and other crew members were either afraid to speak up out of embarrassment of possibly being wrong, or out of respect because the commander was "such a good pilot" or possibly out of fear because the commander was known to "bite off heads" if challenged. The dynamics are as varied as people are but the common thread is, "nobody said anything" and so there were two or three different understandings of the operational situation riding in the cockpit instead of one.
CRM came about because accident investigators realized through the CVR that a perfectly serviceable airplane was flown into the ground or into another aircraft killing a planeload of people because communications did not effectively establish a full, common understanding of the situation.
CRM doesn't end just with understanding.
One example of CRM in action was the United Airlines DC10 at Sioux City, where Denny Fitch, a dead-heading pilot sat behind the captain and First Officer and manipulated the throttles to fly the aircraft to the Sioux City airport. The captain handed control over to someone not even in his crew but who was "best qualified in the moment" to do the job; - "What", not "who". It was a brilliant command decision that saved 185 lives.
I hope this is a bit better explanation of what I was trying to say and that the simplifications are not otherwise patronizing your aviation knowledge. The subtleties of CRM and what CRM has evolved into now would take a much longer post but I hope the idea comes across reasonably well. I think medicine could benefit tremendously from such an approach, though, (as stated), modifications to suit the unique dynamics of medicine (vs aviation) would have to be made.
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mercurydancer;
I'm wondering if you've encountered Dr. Atul Gawande's two books, "Complications", and "Better"?
In Complications he states, in part:
"The British psychologist James Reason argues, in his book Human Error, that our propensity for certain types of error is the price we pay for the brain's remarkable ability to think and act intuitively - to sift quickly through the sensory information that constantly bombards us without wasting time trying to work through every situation anew. Thus systems that rely on human perfection present what Reason calls "latent errors' - errors waiting to happen. Medicine teems with examples.
. . . . etc"
In these fascinating books in which he talks quite frankly about medicine, he does take a few moments to discuss approaches to medicine which draw upon the techniques of CRM. Medical people with whom I've discussed these techniques believe there is a strong need. The driving force for aviation was, frankly, "headlines" - a lot of people dying at once, to be blunt about it. I believe the health industry has a fatality rate that is substantially higher than aviation and even higher than the automobile in the US, (> 45,000/year) but because no headlines result, such rates do not "capture the imagination" of medicines' "safety people", (I doubt if there are such dedicated positions - they might be closer to "risk management" positions?).
I think the value of a "human factors" approach modelled after aviation's approach is high and desireable. However, establishing and changing the mentality of the health industry, (where error and resulting fatalities is a "net positive" for some in the same way that the Exxon Valdez was a "net positive" for Alaska because it raised the GNP of the State...), would face inevitable resistance.
As in aviation, such change usually takes a full generation - about 25 to 30 years, to become established.
Thought you might be interested.
PJ2
I'm wondering if you've encountered Dr. Atul Gawande's two books, "Complications", and "Better"?
In Complications he states, in part:
"The British psychologist James Reason argues, in his book Human Error, that our propensity for certain types of error is the price we pay for the brain's remarkable ability to think and act intuitively - to sift quickly through the sensory information that constantly bombards us without wasting time trying to work through every situation anew. Thus systems that rely on human perfection present what Reason calls "latent errors' - errors waiting to happen. Medicine teems with examples.
. . . . etc"
In these fascinating books in which he talks quite frankly about medicine, he does take a few moments to discuss approaches to medicine which draw upon the techniques of CRM. Medical people with whom I've discussed these techniques believe there is a strong need. The driving force for aviation was, frankly, "headlines" - a lot of people dying at once, to be blunt about it. I believe the health industry has a fatality rate that is substantially higher than aviation and even higher than the automobile in the US, (> 45,000/year) but because no headlines result, such rates do not "capture the imagination" of medicines' "safety people", (I doubt if there are such dedicated positions - they might be closer to "risk management" positions?).
I think the value of a "human factors" approach modelled after aviation's approach is high and desireable. However, establishing and changing the mentality of the health industry, (where error and resulting fatalities is a "net positive" for some in the same way that the Exxon Valdez was a "net positive" for Alaska because it raised the GNP of the State...), would face inevitable resistance.
As in aviation, such change usually takes a full generation - about 25 to 30 years, to become established.
Thought you might be interested.
PJ2
Last edited by PJ2; 22nd Oct 2009 at 22:45.
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PJ2
There are specific roles for patient safety. I'm one of them! Certainly medicine teems with latent failures but there are some factors which arent present in the airline industry which makes a direct comparison difficult. In an airline, unless a passenger dies of natural causes during flight, death is avoidable. The 45,000 you quote is an accurate figure but not all the deaths were avoidable, just that the medical mistakes contributed to the death to a greater or lesser extent. The hard fact is that people die in hospital and the more complex the care then the higher the rate of untoward incident. A thorough analysis of such incidents indicates that the huge majority of incidents have little impact on the final outcome. This by no means absolves medical staff in improving practice.
As Ive mentioned, CRM is more difficult in a medical setting as sometimes it is hard to define a team. In an operating room there isnt one "captain" but three: the surgeon, the anasthesiologist and the nurse in charge. All are aimed at the successful completion of the surgery and are interdependent, but each has the final say for their own particular role in the surgery. No one person has complete control over the OR. Conflict ensues when the aims of each role diverge.
Interestingly enough, a UK airline captain unfortunately lost his wife in a surgical procedure and his analysis of the incident is very much along the lines of CRM failure.
The basic tools for incident investigation within healtcare have been unashamedly taken from transport accidents and have proved to be very useful indeed. Our incident reproting system is years behind the airline industry but is developing.
There are specific roles for patient safety. I'm one of them! Certainly medicine teems with latent failures but there are some factors which arent present in the airline industry which makes a direct comparison difficult. In an airline, unless a passenger dies of natural causes during flight, death is avoidable. The 45,000 you quote is an accurate figure but not all the deaths were avoidable, just that the medical mistakes contributed to the death to a greater or lesser extent. The hard fact is that people die in hospital and the more complex the care then the higher the rate of untoward incident. A thorough analysis of such incidents indicates that the huge majority of incidents have little impact on the final outcome. This by no means absolves medical staff in improving practice.
As Ive mentioned, CRM is more difficult in a medical setting as sometimes it is hard to define a team. In an operating room there isnt one "captain" but three: the surgeon, the anasthesiologist and the nurse in charge. All are aimed at the successful completion of the surgery and are interdependent, but each has the final say for their own particular role in the surgery. No one person has complete control over the OR. Conflict ensues when the aims of each role diverge.
Interestingly enough, a UK airline captain unfortunately lost his wife in a surgical procedure and his analysis of the incident is very much along the lines of CRM failure.
The basic tools for incident investigation within healtcare have been unashamedly taken from transport accidents and have proved to be very useful indeed. Our incident reproting system is years behind the airline industry but is developing.