- What is the threat that the procedure is designed to mitigate or manage?
- What is the justification for the procedure? What does the data say?
- Does the procedure conflict with any other policy or procedure?
- How does the procedure specifically manage or mitigate the threat?
- Is there a potential for undesired consequences from the mitigation strategy? (Additional threats)
- What is the strategy to prevent these undesired consequences?
- How is the procedure trained?
Friday, October 25, 2013
My last post was meant to initiate a discussion about the priority of standard operating procedure in airline operations. Is it important? Why or why not was the type of comment I hoped readers would articulate? Unfortunately, there were few comments pro or con. Therefore, I am going to try to argue both sides of this issue. Those of you that know me understand my appreciation of the “one liner”. So, considering the fact that I am going to have to conduct the debate by myself, here’s a great one.
“I may be a schizophrenic, but at least we have each other.”
I have shared my objective for this blog before. It is to initiate a dialog between airman and aviation related professionals to discuss what we do as well as how and why we do it. Aviation is a very unique activity and therefore requires active participation over a considerable time period to make introspective and vulnerable comments on related complex issues. It is very easy for management or simulator/instructor pilots to be critical and judgmental of the line pilot. It is not an arrogant critique; I have been there myself. The judgment does come, however, from a lack of identification with the everyday challenges that are line flying.
Many companies espouse the primary importance of a safe operation, but out of the other side of their mouths preach efficiency. They have endless charts depicting data that shows where the pilots can be more efficient. There are detailed presentations showing the company’s operational performance compared with the competition. When it comes to a safe operation, however, the strategy is simply procedural compliance. Unfortunately, it’s not that easy.
This reminds me of the young petroleum engineer who asked his mentor, “How can I be successful in the oil business?” The seasoned “oil man” replied, “It’s easy, get up early, work hard, find oil.”
Line Operational Safety Audits, LOSA, demonstrates the vulnerability of safe operations to intentional or unintentional non-compliance with SOP. Error avoidance is always desired, however, error management achieves the same goal and is the essential link between procedure and safe operation. Threat and Error Management IS bridge between procedure and safe operations.
Safety and efficiency are competing priorities, however, not mutually exclusive goals. You can be safe and efficient at the same time, but not without vision, resources, mentoring and experience. The job of the professional airman, specifically that of the airline pilot, has never been more challenging. The machine and the environment have never been more complicated or crowded with threats. A set of best practices is invaluable for airline flight crews. Navigating this “mine field” takes absolute and complete focus by the crew. Every other group the crew interfaces with has their own agenda. Gate, ramp, mx, ATC as well as the customer all have their minds focused on an “on time” operation while at the same time assuming a safe operation. The crew cannot “assume” a safe operation. They are the “keeper of the flame”. They must not lose sight of the primary goal, a SAFE OPERATION, in pursuit of procedural compliance. Delayed flights, lost bags, misconnected passengers, mx delays are all unfortunate situations, but all can be overcome. An aircraft incident or accident cannot be erased. Safe Operations is all about prevention. A replay is not an option. If threats and errors are not managed the outcome is not assured. If the outcome is unsatisfactory, there can be no “do overs”.
Standard Operating Procedure, SOP, is recognized as the best way to ensure a safe operation, however, it is not that simple. Getting flight crews to be highly compliant with SOP is not easy. Crews are not defiant, but they are generally not committed either. By “not committed“, I mean they don’t understand why the procedure is in place and why it is crucial to a safe operation. The rationale is obvious to the one who wrote the procedure, but not necessarily to the line pilot. The line pilot is faced with literately hundreds of competing dynamic threats on each flight, therefore the rationale for a procedure is very important. Prioritization, or “workload management” as it is referred to, is the line pilot’s world. If absolute procedural compliance were really practiced, airlines would rarely operate on time. Some procedures or regulations are written simply for the sake of liability. When things go wrong, the excuse “We told them not to do that”, allows plausible deniability for those upstream in the organization. Very rarely, if ever, do crews that understand the justification for a procedure blatantly disregard it.
Let me emphatically restate my position, Standard Operating Procedure, SOP, is the best way to pursue a safe operation. However, it is not that simple. To get a high level of compliance it requires “buy in”. “Buy in” is the understanding and the internalization of the rationale for a procedure. When airline flying was less complex the “buy in” was much easier. Nowadays the environment is far too complex for the procedural rationale to be self evident or assumed. For “buy in”, airline operators must be able to articulate the answers to the following 7 questions for every procedure. Not every line pilot will ask these questions, but when one does it must be answered satisfactorily. Many procedural justifications are self-evident many are not. Either way, every instructor/management pilot must be supplied with and understand the answers to these questions so that they may educate the line pilots and earn “buy in”.
If these questions can be answered and communicated effectively to the line pilots and there is still intentional non-compliance the airline needs to reevaluate their hiring criteria. Once airlines have committed to hire pilots that understand and value a safe operation, the company’s operational leadership owns the responsibility for “buy in” to SOP.
I will continue the discussion of “buy in” in a future post, but to quote Simon Sinek, the author of START WITH WHY, “there are only two ways to motivate people. You can either manipulate them or inspire them.”