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Wednesday, January 15, 2014

W. T. F. ?

“The landing was uneventful, and all customers and crew are safe," airline spokesman Brad Hawkins said in a statement late Sunday.”

“Airline spokeswoman Brandy King said Monday that the captain and first officer were removed from flying duties while the airline and federal aviation safety officials investigate the mistake.”

Of course Jay Leno had some funny things to say about the mistake, but there is a very serious side to the incident.  These two statements from the same news report of SWA 4013 totally contradict the other. How can the flight be uneventful and the pilots taken off flying status for their mistake?  What was meant by spokesman Brad Hawkins “all customers and crew are safe”.  I guess that was because they were no longer on the airplane.  Before the airplane landed, “the outcome of the maneuver” and the safety of the customers and crew was clearly in doubt.  Fortunately luck overcame human failure.

Last November I posted an article, Do Pilots Rely OnAutomation Enough?, after the “Dreamlifter” 747 flown by Atlas pilots landed at the wrong airport in Kansas.  The anecdote for this or any other type of pilot error is the acknowledgement and ownership of the statement “I AM CAPABLE OF MAKING MISTAKES”.  Pilots without that mindset, no matter how proficient or experienced, will continue to fall prey to their human vulnerabilities.

I am beginning to believe that the culture of the airline industry in general is actively trying to avoid this truth.  I am very reticent to highlight specific operators.  However, in this case it is unavoidable.  I believe we are looking at the tip of an iceberg.  The unusual number of recent incidents at Southwest Airlines requires either an internal or external audit of their flight operation.  This audit is necessary to identify corporate attitudes and cultural attributes, both positive and negative, so that these lapses in safety can be addressed.

The audit needs to a Line Operational Safety Audit(LOSA)The goal of this audit should be targeted at the operations’ approach to safety, not just an audit of procedural compliance.  I am sure that Southwest, like all other airlines, has sufficient procedural guidance to enable its pilots to avoid their string of recent incidents.  So one must ask then, how does this continue to happen? And more importantly, how do we change the outcome?  The LOSACollaborative, under the direction of Dr. James Klinect, provides airlines with the tools and training necessary to audit their operation and assess the collected data.  It also allows for normalization and distribution of data between member airlines.  All aviation professionals have a vested interest in the pursuit of the highest level of aviation safety.

Nearly 20 years ago, a Continental Airlines DC-9 landed gear up at Bush Intercontinental Airport (IAH).  Even though no one received even a minor injury, the airline’s management took a courageous approach to that profoundly avoidable accident.   Instead of looking at the accident as just a failure of the pilots, they looked at the operation as a whole.  Just like the 737 crew landing at the wrong airport, the DC-9 pilots had SOP’s in place that would have prevented the gear up landing. 

The paradox was, and still is, “What is the procedure that ensures SOP’s will be followed?”.  How do crews escape the inevitability and consequences of human error?  Humans CAN and WILL make errors.  The only solution is to accept their existence. The only antidote is mitigation.  As humans we cannot successfully avoid or ignore errors.  They must be embraced and accepted as inescapable.  Unfortunately, pilots like other very proficient and highly motivated individuals are the least likely to accept their fallibility.

It took the leadership of Continental CEO Gordon Bethune, the commitment of flight standards and training, the guidance and research of Dr. Robert Helmreich and his team at the University of Texas, and the willingness of the line pilots to develop the safety management approach we know today as Threat and Error Management (TEM).   LOSA is an integral component of an effective TEM program.

I have asked this question many times, “Is the goal of airline operations safety or procedural compliance?”  Will procedural compliance guarantee safety?  Is having a published procedure a guarantee that pilot errors will be eliminated?  Is it just process or the achievement of an objective? 

I will agree that landing a 737-700 on a 3700’ runway is an impressive piece of airmanship.  However, like performing surgery on the wrong body part, doing the wrong thing well is still doing the wrong thing.  The last time I had surgery done the team in the operating room asked me a list of questions that ensured they were dong the right thing to the correct part on the intended individual.  Just requiring a list of questions, i.e. creating SOP, will not eliminate error.  To do that requires a mindset that includes the acknowledgement of error.  Not just error in general, but that each person involved might be the one to make the mistake.  The understanding that SOP is not the ultimate goal.  Rather, it is a tool to manage error. When that mindset exists, the individual and the organization are able to look at threats that exist in them or their environment that causes humans to make unintentional errors.

Will Southwest, or any other airline for that matter, have the courage to look internally and ask, “Do we train our pilots to manage inescapable error or do we just write procedures, expecting an unachievable error free execution of these standard operating procedures. 

Time will tell, but I am worried.


  1. Has it been your experience that a LOSA can measure the state of one's mindset or the corporate culture of the pilot group? It is my understanding that a LOSA does a good job of identifying common threats and errors, but how do you identify and communicate an unhealthy culture?

  2. I think an unhealthy culture could be easily identified thru observing our actions in the cockpit. Are we talking more about company issues or discussing threats for the particular phase of flight we are in? What about the interaction between the pilots? Are we still displaying professionalism? Are we willing to submit a safety report for the good of the company or do we care anymore?

    I'm not sure, but I think part of a LOSA includes a pilot survey and Interview. I think the simply question, "how would you rate the culture, healthy or unhealthy?" would answer the question. The bigger question is, would the company be afraid to ask the question.

  3. LOSA's conducted under the guidance of Dr. Klinect and his team can tailor the LOSA to capture different facets of an Airline's operation. In review, a LOSA is a no jeopardy event using observers who are line pilots themselves. With this in mind, it's amazing how the observers have a "fly on the wall" perspective. Crews typically don't alter their behaviors for the observers.

    Dr. Klinect then "calibrates' observers to uniformly collect and notate Threats, Errors, and Undesired Aircraft States. Narratives are written that are crucial to understanding "how" a crew managed or mismanaged the Threats they encountered. After this data is sorted and analyzed by Dr. Klinect, it's presented to an Airline's Flight Operations Mgmt. The data speaks for itself. It's up to the Airline's Mgmt. to draw it's own conclusions from the data and use the data to responsibly act upon those conclusions.

    As mentioned in the above Blog, acknowledging one's vulnerabilities is an important 1st step. Secondly, SOP compliance and CRM/TEM are not mutually exclusive. It's a symbiotic requires the other.

  4. Excellent points all!

    LOSA should to be thought of as a mirror not a report card. It is a tool that would allow an operation to evaluate, in private, their effectiveness in managing safety. The trends from the "de identified" data can be shared for the company and industry's benefit.

    Let's remember, the Southwest crew did not intentionally land at the wrong airport. What tools, both technical and crew resource management, did they have available that night? Which ones did they use? Is this crew unique or representative of the operation as a whole? The answer to those questions would give valuable data about culture and mindset.

    Once again though, LOSA is a process that should be done in private with trained consultants, not in public by the traditional media.

  5. LKH - I see. However, is there not considerable bias using pilots from the same airline to gauge the mindset/culture of their fellow pilots when they usually have little experience to compare it to? Most pilots have flown at only a few carriers in their careers.

    John - When giving the results to management, are there some markers or comparisons that can be made to judge the severity of the issues presented? Is information "calibrated" sufficiently to report comparisons with other industry participants?

    Jim - I guess that is my ultimate question about LOSA. Is the "mirror" effective if you are the one holding the "mirror"?

  6. That is EXACTLY right. The mirror only provides a reflection, all the judgement comes from the one holding the mirror if they choose to look. Looking into that mirror is a courageous undertaking. What do we do with what we see????

  7. Tye, before a LOSA's final results are shared with management, Dr. Klinect's data is calibrated through a round table process involving Dr.Klinect, his researchers, and representatives from an airline's Flight Operations. During this round table, all documented Threats, Errors and UAS's are reviewed to insure all were correctly cataloged. If there are questions or disagreements, they are answered or resolved to everyone's satisfaction. Final reports are written and Dr.Klinect shares his findings with management. Dr. Klinect is able to make comparisons to other airlines through the LOSA Archive that has been created from LOSAs conducted from over 48 airlines worldwide observing some 12,000 flights involving 9000 crews. (courtesy of the LOSA Collaborative) After that, it's up to the airline to use the data to implement the changes they want; if any. If changes are made, a follow up LOSA needs to be conducted to measure if the changes made were successful or not.

  8. "Fortunately luck overcame human failure." Luck is the ultimate determinant of our safety system.

    "Humans CAN and WILL make errors." That's why we have accidents.

    "All aviation professionals have a vested interest in the pursuit of the highest level of aviation safety." Actually, they don't.

    "After that, it's up to the airline to use the data to implement the changes they want; if any." They don't want any.

    I have asked this question many times, “Is the goal of airline operations safety or procedural compliance?” Neither. The goal of airline operations is profit.

    "And more importantly, how do we change the outcome?" We can't and we won't, no matter how hard we try.

    We are doomed to luck being our savior.

  9. Great comments!

    Profit is not a 4 letter word. It is one one goal of an airline. Safety is another. They are competing, but not mutually exclusive elements of the business .

    Luck is also a component of the the aviation business. Bad things happen. However, effective pilots create a safe outcome by preparing for these bad things to happen, not just hoping they don't.

    Buying lotto tickets is not good retirement planning.

    1. Tye: There is nothing at all funny about lost lives. What do you imply?

      Captain Blaszczak: Nothing in my post equated profit with a 4 letter word, it merely stated a goal inherent in any business. “Safety” is not at all a goal of an airline. It is merely an expense that is mitigated through risk analysis. The fact is, airlines are quite willing to accept a defined level of risk in their operations. Ultimately, it’s about the money.

      To posit that “effective pilots create a safe outcome by preparing for these bad things to happen” falsely makes it the job of the pilot to “fix” everything that is WRONG with the airline safety system. Indeed, pilots are at the ‘sharp end of the knife’ when accidents happen. But conditions far beyond their involvement conspire to the eventuality of an accident.

      Airlines buy lotto tickets, and they regularly win. Pilots can’t change that.

  10. Oh, Perhaps I am reading you wrong. See my interpretation in paranthesis below.

    "Fortunately luck overcame human failure." Luck is the ultimate determinant of our safety system.(Far, far from luck. Enormous amounts of hard work, training, and procedural changes and have taken place to reduce accident/fatality rates to a near zero level. The rates of occurrence continue to decline. I will say that I believe it is impossible to calculate the risk of consequential rare events and predicting their occurrence. Perhaps this why you would consider it luck.)

    "Humans CAN and WILL make errors." That's why we have accidents.(That is one of the reasons why we have accidents.)

    "All aviation professionals have a vested interest in the pursuit of the highest level of aviation safety." Actually, they don't. ("Aviation professionals" and most non-professionals do have a vested interest in the "pursuit" of the highest level. It is not always achievable for a variety of reasons.)

    "After that, it's up to the airline to use the data to implement the changes they want; if any." They don't want any. (Well, the reality is that managers make changes constantly to improve both the safety and efficiency of the airline. I guess you could say they are doing it against their will.)

    I have asked this question many times, “Is the goal of airline operations safety or procedural compliance?” Neither. The goal of airline operations is profit. (The goal of "airline operations" is to effectively transport people and cargo safely and efficiently from point A to point B. It is the goal of airline management to figure out a way to do that profitably.)

    "And more importantly, how do we change the outcome?" We can't and we won't, no matter how hard we try. (Aren't we fortunate to have such low accident/fatality rates that we can now focus on reducing incident rates. Incidents that result in damage or injury continue to occur. Most of which the masses know little about.)

    We are doomed to luck being our savior. (I sure hope not. Personally I still see many areas that need improving and luck would imply we should just throw our hands up and surrender.)

    1. Yes, you are reading me wrong but I see that my intended points were not clear enough. The intent was to note areas and attitudes in the aviation safety system that prevent us from making substantial improvements in it.

      In short, I completely support the efforts of the blog host. Considerable efforts by many have improved our safety system. These efforts must be increased many fold. As I noted above and meant to imply in my previous posts, safety efforts are being impaired by a lack of enthusiasm and other forces that hinder further progress.

      Not at all time to surrender; it’s more time to attack.

      Thanks for continuing the discussion.

  11. Anonymous, I was afraid I might be misinterpreting your point. I agree that there is a general apathy toward the esoteric nebula of aviation safety science. Most pilots are practitioners and have trouble comprehending the relevance of the abstract. They are much easier to persuade with anecdotal evidence than charts, graphs and theory. Show a pilot/manager statistical analysis of a relevant problem and get a glassy-eyed stare. Show that person a single video animation of the problem and you have their attention.
    I also agree with you that the host of this blog provides valuable insight for those that practice aviation safety. He obviously "gets it" as a synergistic whole. I am not sure many aviation safety Managers truly grasp the potential benefit of integrating the different safety programs into a cohesive picture. Most are still in the piecemeal stage as each program works independently to reach their own bureaucratic solution. Perhaps their is some logic/vision I am not seeing.