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Sunday, April 28, 2013

A Rose By Any Other Name……

When things appear to be different, that difference may be more a matter of perspective than difference. In fact the two might be the same as demonstrated in the iconic Checkerboard Illusion, by Edward H. Adelson

There are two perspectives in the aviation safety management universe.  The angst between these two camps is not as passionate as that between Shakespeare’s Montagues and Capulets, but like these two families they are really not that different.  

The first camp says that the way to a safe operation, i.e. risk management, is to plot the coordinates of computed probability and severity on a “risk” graph and decide if the result is in the “green” or safe zone. This is known as a risk assessment process.   The risk assessment provides both the evaluation of the risk as well as an opportunity to look for ways to adjust or manage the probability and/or severity to a more “acceptable” value.

 
The second camp says that the way to a safe operation is to identify and manage threats to drive the actual probability toward zero while for operational purposes, assuming there will be an occurrence.  Then evaluate whether, if there is an occurrence, are there are measures available that will allow the airplane land safely. 

Both of these groups are trying to reach that coveted “green zone” that signifies a safe operation.  Aviation is inherently dangerous and therefore risky by nature.  I’ve talked about this before. We cannot eliminate risk in aviation.  Risk in aviation can only be managed.  How then, can it be “managed”?  How will we know when risk has been managed effectively?  Hint, the outcome is never in doubt.

This take us back to the matrix.  The lower left block, 1 on the probability/severity scale, is the one we’re looking for.  Unfortunately, zero does not appear in the matrix.  How will we know if we are in that box?

Those who see risk on the probability/severity graph would endeavor to introduce elements into the operation like procedures and technology as well as training to lower the probability of the risky event or condition.  In addition they would like to introduce similar elements that avoid or neutralize elements of the operation to decrease the severity of a given condition.  This was the motivation behind Safety Management Systems, SMS.

 

We have to decide what risk is acceptable and what is not. What methodology do we use to determine acceptable risk?  FAA Advisory Circular 120-92A, Safety Management Systems for Aviation Service Providers, gives us some guidance.  However, the framework and structure outlined in the Advisory Circular are mainly targeted at the organizational level.  What about at the crew level?  Whereas the traditional risk assessment process relies heavily on a high level of compliance and performance, reality has shown that a successful outcome is more dependent on awareness, analysis and decision making. Is SOP compliance enough to mitigate risk?  Is 100% crew compliance any more achievable than attaining zero risk?  What is the minimum level of human performance necessary for a risk assessment to be valid?   
  
This is where Helmreich, Merritt, Klinect, et al were way ahead of their time.  They asked probing questions and came to the following conclusion.  Organizational risk management, in the form of standard operating policy, is not enough.  It is only half of the answer.  Total risk assessment and management must include the crew as well.  In a dynamic environment like aviation, policy and procedure provide a solid foundation and provide and excellent framework, but are they enough?  What role does culture play in risk management?  How can risk truly be managed to an acceptable level if human error is not included in the equation?

For a crew in an operational environment, I believe the boundaries of acceptable risk for any condition are defined by a probability as low as practicable and a degree of severity that will, with reasonable mitigation, assure a safe outcome.

This is the rationale for Threat and Error Management, TEM.  It is the link between organizational risk management, SMS and crew performance.  TEM recognizes the strengths and the weaknesses of human performance within the overall safety management system.  Each risk can be expressed by a set of unique threats.  Threats are commonly described as operational events that occur outside the influence of the crewmember, increase operational complexity and/or require crewmember attention to maintain safety margins.  When these threats are effectively managed or mitigated, the risk may be considered acceptable.  Weather events are an excellent example.  In cases when the threats of the condition can be managed to a safe outcome the risk is acceptable.  When they cannot be managed or there is doubt, the risk is unacceptable. 

There are many components to an effective management or mitigation strategy.  The primary and most important component is appropriate compliance with SOP.  It is the soft skills of situation awareness, leadership, decision making, communication, monitoring as well as workload and automation management that allow crews to effectively apply SOPs to the dynamic situation.

As previously mentioned, a major weakness of the traditional probability/severity risk management paradigm is the component of human error.  Errors are commonly referred to as crewmember actions or inactions that lead to deviations from crew or organizational expectations or reduce safety margins.  Errors may occur from spontaneous human error with no threat present or mismanagement of an existing threat.  The foundational strength of error management is the acceptance and preparedness for crew error.  It is the recognition and ownership of the inevitability of humans to make errors.  Therefore, the goal is to identify and mitigate errors before there is a negative consequence rather than to naively assume an unrealistic and unachievable level of human performance.

Like the overwhelming love that Romeo and Juliet shared, so do Risk Assessment and Threat and Error Management share the bond of safety.  The young couple agonized over the barriers of their surnames.  What tragedy might have been averted had one not been named a Capulet and the other a Montague?

JULIET

O Romeo, O Romeo! Wherefore art thou Romeo?

Deny the father and refuse thy name;

Or, if thou wilt not, be but sworn my love.

And I’ll no longer be a Capulet.

ROMEO (Aside)

Shall I hear more, or speak of this?

JULIET

‘Tis but thy name that is my enemy;

Thou art thyself, though not a Montague.

What’s a Montague? It is nor hand, nor foot,

Nor arm, nor face, nor any other part

Belonging to a man.  O, be some other name!

What’s in a name?  That which we call a rose

By any other name would smell as sweet;

So Romeo would, were he not Romeo call’d

Retain that dear perfection which he owes

Without that title.  Romeo, doff thy name,

And for that name which is no part of thee

Take all myself.

Saturday, April 27, 2013

Safety, It Takes A Village


Former NTSB Chief, James Hall, recently wrote an OP-ED piece, ABack Seat For Safety at the F.A.A. for the New York Times.  First of all, I have tremendous respect for Mr. Hall’s service to our country, both in his military career as well as his time at the NTSB.  Freedom and safety are both honorable pursuits.

I would have to disagree with his first point that the FAA and aircraft manufacturers have conspired, through their “cozy relationship” to place safety behind other objectives.  This statement is reinforced with an adjacent graphic that depicts an airliner going down in flames with the smoke trail formed into an “A-OK” hand signal.  The relationship between business and government is always complicated.  Extremely so in an industry as highly regulated as commercial aviation.  I think it is inappropriate to demonize either party by that characterization.

Chairman Hall’s assertion that government oversight “helps” prevent fatal accidents is spot on.  That oversight is an effective framework from which companies can submit for approval plans to achieve a safe operation.  The FAA is incapable of doing it on it’s own.  One of the biggest reasons is that the FAA does not, in most cases, have the expertise to adequately evaluate their areas of responsibility.  The government just doesn’t work that way.  Most operators and manufacturers have far more knowledge and experience in the technical areas than the government. Without private/government cooperation it would be like having people from the Postal Service overseeing FedEx.  That is why they need each other.  They need to work together.

A problem with rapidly advancing technology is that sometimes it outpaces the regulatory system.  Evolving battery technology is a very relevant topic.  Representatives from the transportation industry recently discussed it in front of the Board.  I think both the NTSB and Boeing’s Mike Sinnett agreed that the testing and failure analysis of the 787 batteries were not thorough enough.  Again, it was a team failure, not a conspiracy to subvert safety.  The FAA’s grounding of the airplane allowed for that testing to be revisited.  The plan that was certified achieved two objectives.  First, the potential for a battery event was lowered.  Second, since the probability of an event can never be zero, a modification was developed that would protect the aircraft in that case.   How can this be described as short sighted and a “regulatory failure”?  I might agree with Mr. Hall that the process up to the grounding could be called a “regulatory failure”, but certainly not the outcome.

Mr. Hall admonishes the FAA for certifying the modifications, “without even knowing the root cause of the battery problem”.   Before he became Chairman the NTSB issued its findings on the crash of United Airlines Flight 585, March 3, 1991, at Colorado Springs, Colorado.  The original probable cause for the accident published by the NTSB stated, “The National Transportation Safety Board, after an exhaustive investigation effort, could not identify conclusive evidence to explain the loss of United Airlines flight 585.”  The FAA made only recommendations after that accident.  It was not until USAir flight 427 crashed 3 ½ years later that the investigation was reopened during Mr. Hall’s tenure and targeted the rudder system malfunctions as well as other controlability issues.  I would consider that an ultimate success as well.

I also disagree with Mr. Hall on another point.  I don’t think additional direct congressional involvement would itself improve safety.  Introducing additional political considerations into safety would not be helpful.  The theatre of congressional testimony might be too big of a distraction from actual problem solving. We need only look at current events concerning the ATC system for evidence.

I will conclude the same way Mr. Hall did, acknowledging commercial aviation’s safety record.  To continue that track record I would strongly advocate a steady course.  Let’s continue to do the things that work. Most important among them is teamwork.  I maintain that all the stakeholders, FAA, NTSB, manufactures, operators, crews and passengers are all committed to a safe operation.  It takes every one of us, every day, every rivet, every flight to build this safety record.  We need to support and learn from each other, not get caught in the trap of a blame game.  That contest has only losers and no winners.

Friday, April 26, 2013

A Mind Of Its Own


This post is an expansion of my comment to Air AmbulancePilot Demonstrates How Deadly Distraction Can Be a post on Christine Negroni’s aviation blog, Flying Lessons.  Her post is an excellent discussion of the NTSB’s finding that among a host of other errors, inappropriate cell phone use was found to be a contributing factor in an air ambulance fatal crash as well as many other transportation accidents.

The genius of Walt Disney helped my generation, all Mousketeers at heart, to adopt the practice of personification, which is the act of giving inanimate objects human traits.

From the legions of brooms in Fantasia to Mrs. Potts and Mater, the loveable tow truck, Disney cartoons have allowed inanimate objects to literally come to life.    But, they’re not alive, they’re fictional characters.  Their sensitive, brave and quirky personalities belong to the brilliant minds of animators, writers and voice talent. 
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The concept of personification is not new.  Mythology allowed ancient civilizations to make sense of their world by explaining concepts through physical form.  For example, the Greek Titan, Atlas, was a god responsible for holding up the earth.  More recently, Hollywood mythology has given us a crime solving Volkswagen and a futuristic odyssey that has a computer taking over a spacecraft.  Ok, that one may not be so far fetched.

Humility plays a role in personification as well.  An artist like my daughter might assign her work to inspiration.  It’s not uncommon for an artist to dismiss the strokes of the brush to things other than talent.   Pilots will often downplay their skills as well.  Chuck Yeager, popularized in “The Right Stuff”, personified the “ah shucks” demeanor of a simple pilot cowboy.  He was anything but simple. Test pilots of his genre had to have high intelligence, extraordinary flying skills as well as uncommon courage. 

Sometimes, at my workshops, I pass out cheap pens at the beginning of class.  They are all identical.  I ask the participants to use them during the class.  At the end of the day I will ask, “What is unique about your pen?”  After a brief comparison some might ask, “Because it is mine?”  Exactly.  A pen has no motive or intelligence of its own.  It is a tool that expresses the purpose of the user.  A pen can write a poem, a lie, a love story, a check, a TO DO list or draw the plans of a new invention.  Like the pen, cell phones, automobiles, airplanes, guns, lawnmowers, books and all the other inanimate tools we use in our lives have no responsibility for how they are used.

In safety management and analysis as well, we get into trouble when we “personify” objects.  Whether it is a hammer, a gun, a cell phone, a box cutter, or a book, an inanimate object has no control of its use.   Organizations and managers responsible for safety get caught in the trap of personification as well.  A book of information and procedures is still just an inanimate object.  Those who believe publishing a memo or procedure will ensure compliance or a specified outcome are as naïve as those who think Herbie, The Love Bug, is a real car.  Even when the procedure is trained and evaluated, it’s objective is never assured.  Compliance is only assured if the human responsibly and consciously executes the procedure appropriately and effectively.  For proof, consider that there are still people getting their fingers and hands cut off by lawnmower blades in spite of extensive “idiot proofing” procedures and devices. Once again, the object, be it lawnmower or operators manual, cannot control itself or the user. 

There are many obstacles between a human and procedural compliance.  The least common of these is willful unsafe operations.   Not effectively managing all the threats associated with an object is not willful unsafe operation.  It is a lack of understanding or perspective that can be addressed by additional training.  Willful or not, how the object is used still rests solely with the user.  Rarely, is the misuse of an aircraft intentional as in the case of 9/11 which is an entirely different discussion.

Almost always the misuse is unintentional like the case of this crashed helicopter, as well as most other aviation accidents.  I say unintentional because I always assume commercial pilots do not intend an accident when they are planning or flying their trip.

For these reasons we need to expand Threat and Error Management training so that we reduce the unintentional misuse of inanimate objects.   TEM is a perspective that pursues a safe operation by identifying threats and errors then preparing for and correcting them to avoid negative consequences.  It all starts with awareness of the situation.  Identification of the threats and acceptance of the human vulnerability to them is the key.  The improvements in outcome will come quicker and be more economical when we endeavor to train the user rather than focusing primarily on the object.

If the helicopter pilot actually understood and considered the threats associated with his behavior, or recognized and corrected his errors before they became consequential, I doubt if there would have been a crash.  It’s not easy, but it’s not complicated either.  There is a profound difference between humans and inanimate objects.    Humans have the potential to control what they do.  That doesn’t mean they always will.  The most vulnerable part of a human is that of distractibility.  Because the human mind has evolved for speed over accuracy it can be tricked very easily.  The discussion of all the human factors associated with this topic is too extensive to cover here.   Recognizing this limitation, however, is one of the greatest challenges in aviation.

Just like any other tool or object, IT’S NOT ABOUT THE CELL PHONE.  It’s about how the cell phone is used.  When humans are working with inanimate objects the most influential as well as the most error prone element in the relationship is the human.  This axiom is especially true for airplanes.

Monday, April 22, 2013

Airlines, Airliners and Pilots in the Digital Age


In 1978 when I entered the airline industry, the preflight routine of a B727 crew was to turn on the window heat, “No Smoking” and “Fasten Seatbelt” signs and set the parking brake.  Now the first and most important step in a lengthy preflight routine is to establish a data link connection between the aircraft and all the digital networks that the aircraft and crew must communicate with.



The airplanes are now “fly by wire”.  There is no longer a mechanical link between pilot and airliner.  Digital signals are sent from the pilot to the airplane via computer-generated commands to the flight controls.
 
In 1934 Elrey Jeppesen started publishing his aeronautical charts.  These charts are carried from plane to plane in a large heavy case. That system was essentially unchanged until the recent introduction of the “electronic” flight bag, made possible by digitizing the charts and storing them in an onboard computer database.


Denver International Airport, one of the most modern airports in the USA, finally opened in 1995.  It was delayed for most of a year and was the epitome of construction debacles when the automated baggage system that United Airlines had specified could not be debugged.  The system was eventually abandoned in favor of the traditional “tug and cart” method of getting baggage to and from the airplanes. 


Bar code readers now keep track of luggage and link each bag to the customer, their location and all their personal and travel info.  This information is instantly available throughout the airline including the dispatchers who are responsible for loading the aircraft.

Inflight entertainment has certainly benefited from the digital revolution.  When airlines first introduced the amenity, it was essentially home movie technology.  A single movie was shown on a film projector and a screen with audio heard through plastic tubes stuck in your ear.   Now virtually hundreds of video and audio selections are available and noise-canceling headphones allow passengers to actually hear what they are listening to.



In addition to all the operational improvements that digital technology has made possible, there are many benefits to flight safety.  Possibly the greatest of these is the collection, examination and distribution of data that helps operators and pilots improve human performance.  Data obtained from digital recorders on board modern airliners as well as observed data help pilots fly safer.  Pilots can look at their own experiences and as well as the experiences of others and use that information to avoid threats and errors more effectively.  The ability to collect, store and widely distribute (after de-identification) this information has dramatically improved flight safety.  This would have been totally impractical before the advent of digital information management.



Despite all of the improvements in the airline industry that have been made by digital information there is one unintended threat.  As a result of the merger of United and Continental Airlines there is currently an arbitration to resolve the outstanding issues involving the seniority integration of the pilots of these two airlines.  The arbitration hearings are legal proceedings and therefore are conducted with and by legal counsel.  Evidence is presented and the three-member panel will render its decision.  Like any other proceeding of this type it is open to the public and the testimony is recorded in a written transcript. 



Airline pilots’ seniority controls everything about his or her career from pay to vacation to scheduling.  The result of the seniority arbitration will control the rest of their career.  The result of this arbitration, by rule and agreement of the parties, will be final, binding and cannot be challenged.  There is a lot riding on the outcome of the panels ruling.  Each side, individually and collectively, is VERY emotionally invested in the outcome.  It can be summed up by this quip.  The difference between a 3 year old throwing a tantrum over candy at the grocery store and a pilot who is unhappy with their outcome in a seniority arbitration is that the 3 year old actually has a slight chance of getting what he wants.





 Each side of the arbitration, consisting of the pilots of their former company and their attorneys will present evidence supporting why their version of the order of the pilots in the combined list should be adopted.  Each side will present witnesses and evidence to defend their position.  As a result, some of the testimony will contain potentially inflammatory rhetoric.


Much like a couple that is dissolving their marriage, the two pilots groups are in court because they could not come to an agreement on their own.  Also, not unlike a couple going through a divorce, the attorneys will try to represent their respective clients as vigorously as possible.   In both proceedings, divorce and seniority arbitration, the parties must listen to the attorneys point out an unflattering and negative description of the other party’s case.  This can be extremely uncomfortable to listen to and almost impossible to view objectively.  The profound difference with the seniority list arbitration in contrast to the divorce is, when it’s all over, after everything has been said, when the decision is handed down, the parties have to move in together and try to make their relationship work.  This will be a huge challenge.



This is where the digital transmission of large amounts of printed data has impacted the seniority integration process.  Unlike years ago when attendance was required to hear the case in real time, now the entire transcript, the good, the bad and the ugly, is available in almost real time to the pilots.  It’s not necessary to attend the hearings to know everything that is said.  The classic sausage metaphor is applicable here, “something that is better not watched while it is being made.”  Also, “after it’s cooked, having watched the sausage being made, or reading the list of ingredients, will not improve the taste.”  However, to ask pilots not to read the transcript is like asking people not to look at photos of a gruesome accident.  It might be prudent, but most humans are not that disciplined.



What would be some strategies to prepare for this threat?  How can the threat of an emotional reaction be managed?  What could be the consequences of this threat is not effectively managed?



The SLI (seniority list integration) distraction is a threat that must first be identified and then managed by both the airline and the pilots.  There must be strategy to prepare for the angst that will develop from this emotional process.   Just as effective pilots do when they are faced with an operational threat, the airline and the pilots must identify and prepare for this emotional threat.  Every pilot from both sides must use all the resources available to them to avoid the possible errors that might result from this distraction.  The primary and most effective resource any crew has is their professionalism and commitment to a safe operation.  Additionally, the airline cannot rely solely on their crews to manage the threat.  They must actively provide resources and support.  Success will not be easy, but the benefits will be worth the effort. 




I would suggest the example of NFL players.  When the game is over, it’s over.  The trash talking, the hard hits, the penalties, the missed opportunities are left on the field. After the game, these professionals meet on the field and acknowledge the effort each team showed.  The game is over.  It’s time to move on.  Even when there’s a lot riding on the outcome. Even when it’s a playoff game, it’s the same.  The fans, the teams, the players, either elated or disappointed, usually find a way to accept the outcome. Events are just events. The response to an event is a personal decision and a demonstration of character. It’s always a tragedy when individuals use events as justification for inappropriate or destructive behavior.

Sunday, April 14, 2013

Titanic - Ship of Dreams

My daughter, Scout, is quite the Titanic aficionado.  In fact when the Titanic exhibit was last in Houston at the Museum of Natural Science, she actually knew things the tour guide didn’t.   

Tonight at our house, on the 101st anniversary of the sinking, we are having a Titanic film festival on our big screen HD.  I asked Scout what she thought were the most profound elements of the Titanic tragedy.   These are her 5 things.


1). Lifeboats.



There were 20 lifeboats aboard the Titanic. It was the president of the White Star Line J. Bruce Ismay’s view that as long as the number of lifeboats met the board of trade’s regulations, everything would be okay.  Unfortunately, not only was there an inadequate number of lifeboats, there was also a capacity issue. Nearly all of the lifeboats were launched half full.

2). Lack of Binoculars


Just before the Titanic was due to set sail from Southampton, one of the ship’s crew members was demoted and asked to leave the ship. But when he did, he accidentally took with him, the key to the locker that held the binoculars for the lookouts. This simple mistake resulted in the lookouts relying on their own eyesight to watch for icebergs.



3). Ignored Ice Warnings.



The Titanic received numerous ice warnings throughout the day on April 14, 1912, However, due to idea that the Titanic was considered to be ‘practically unsinkable,’ many, including Captain Smith thought there was little cause for alarm.  More so, the last boilers were lit, so the ship could speed up.  This was so the ship could [supposedly]  break a speed record and arrive in New York a day early.



4). Construction.



The Titanic had 16 watertight compartments. The ship was designed so should any of the first four compartments flood, the Titanic could ‘act as her own lifeboat’ and remain afloat. The disaster that took place on the night of April 14,1912, was considered the worst possible thing that could happen.



5) Weather Conditions.



On the night of April 14, 1912, at 11:35pm local time as the Titanic sailed 400 miles off the Grand Banks of Newfoundland, the water was still as glass – unusually calm for North Atlantic weather in April.  There was also no moon. Scientist hypothesized that due to the calm weather an moonless night, it would be much more difficult to spot icebergs. 


There were many threats for Captain Edward J. Smith to consider.  He and his crew made some fatal errors as well.  His 26 years experience gave him confidence that all was under control.  The legacy of Captain Smith haunts us all.  On modern day jumbo jets, just like the magnificent ships that proceeded us, passengers cross the oceans confident that that we, the crew, are looking out for them. 


If Captain Smith could speak to the crews crossing the Atlantic tonight, what would he say to them?  What would be his advice?   How could he help us avoid his tragic destiny?


RIP Captain Smith and the other 1502 brave souls who perished that fateful night


Actor Observer Asymmetry

Regular readers of this blog know that I am an unabashed champion of the safety strategy know as Threat and Error Management (TEM).   Simply stated, TEM is a perspective that pursues a safe operation by identifying threats and errors then preparing for and correcting them to avoid negative consequences.  There is no procedure for TEM.  There is no recipe to follow.  It is a mindset.  It is a continual critical assessment of the situation.  To quote Gerry Bruggink (1917 – 2005), former Chief of Human Factors for the NTSB, “most accidents are caused by uncritical acceptance of easily verifiable assumptions.”  TEM calls for evaluating one’s assumptions and continual monitoring of the dynamic situation to be aware of changes.  In aviation, the dynamic situation always includes errors in human performance.


Human cognition is incredibly complex and very difficult to understand.  The results of free will can be hard to predict and can be easily subverted.  For decades Madison Ave. has used this fact to manipulate consumers.  Illusionists routinely convince people they see things that don’t exist or didn’t happen.  People still choose to stick their hands in a running lawnmower is spite of sophisticated “safety” devices.

What causes pilots and others in highly technical occupations to abandon or reject best practices and engage in risky behavior in spite of their training?  It starts with a conscious or an unconscious assumption that “it can’t/won’t happen to me”.

When facilitating human factors workshops I often show a picture of a man engaged in obviously risky behavior.  He is sitting under his truck, held precariously by a couple pieces of wood, welding on the gas tank.  I ask the participants to comment.  The response is universally quite judgmental.  A "Darwin Award" is usually suggested.  Next, I ask the class if they feel that driving while talking or texting on a smartphone can be dangerous.  They answer in the affirmative.  Finally, while raising my own hand, I ask who has driven while talking or texting.  “What is the difference between us and the man in the picture?”, I ask.

Evaluating the origins of our own behavior and that of others is one of the biggest obstacles to the adoption and integration of TEM into airline operations.  This difference between how we interpret the cause of our actions or errors and how we see it in others is known as Actor-Observer Asymmetry or Bias.  This was first proposed by social psychologists Edward E. Jones and Richard E. Nisbett in 1971.  They concluded, “The actor may simultaneously view his own personality as being more unique than it is and his own behavior being more appropriate to given situations than is the behavior of others.”   This trait is not a disorder.  It is a “normal” human characteristic.    However, like many human traits like distractibility, it is the classic Catch-22. “I'm only OK if I know I am not OK..”

TEM requires that we see ourselves as both actors and observers.  We need to see in ourselves our uniqueness as well as our sameness with those we observe.  If we actually thought we would crash our car while talking on our mobile phone we wouldn’t do it.  At the same time we absolutely accept the premise that others might crash and therefore consider it an unsafe practice for the general population.  We believe that when we arrive home safely after talking on our mobile phone it is because of our ability and not that we were perhaps lucky.  Things that may be seen as a threat in the abstract are not a threat for me practically. During the workshops we often do case studies on noteworthy accidents.  I am always intrigued by the "Actor Observer Bias" demonstrated by some participants in these case studies.   The "I would never do that." expression on their face is easy to recognize.  It is difficult for most pilots to put themselves in the position of the accident/incident crew. 

Actor Observer Asymmetry is a major obstacle to error recognition and avoidance.  As obvious as it sounds, it’s difficult to avoid errors you don’t think you’re likely to make.  All humans make errors.  Let me say that again, all humans make mistakes.  It is impossible to avoid all of them.  However, it is possible to recognize and correct errors before there is a consequence.  Therefore, it is also necessary in these workshops to demonstrate how easy it is to introduce errors into human cognition.  There are many simple “parlor tricks” to demonstrate, "to err is human".  These help to reduce the asymmetry between the class participant (observers) and the crew in the case study (actors).

Although aircraft have become more reliable through advanced technology, the human brain hasn't changed since Kitty Hawk in 1903.  There are many lessons that can be learned from 110 years of aviation, but only if we believe those lessons apply to ourselves, not just the other guy.