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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. 
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.

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