Butterflies, Bunnies and Unicorns

One of my all time favorite attractions at Disney is the Carousel of Progress.  It is a very entertaining celebration of entrepreneurial achievement.  There IS a “great big beautiful tomorrow”.  However, behind every one of those “modern” conveniences is a story of imagination, failure, struggle and frustration before there was an invention or product,

Innovation is messy.  There is a price to pay for the advancement of technology in the pursuit of a better way doing things.  Technology that works in a laboratory is not necessarily ready for prime time.  Sometimes it needs “real world” testing.  This is especially true of how we power our life, specifically transportation.

A case has been made against fossil and nuclear generated energy.  It is essentially an issue of safety.  Is it safe for the environment?  Is it safe for people living near power plants?  Ok, what’s the practical alternative?  Reddy Kilowatt cannot do his work if there is no viable and acceptable power generation and distribution system. 

 

In addition to the aesthetics, wind has its own set of environmental problems.  Some are deforestation, erosion and deaths of substantial numbers of birds of prey.  Solar power is promising, but not yet practical.  Solar panels are expensive, need continual maintenance and/or replacement and are at best 40% efficient.  This compares with up to 60% for natural gas power plants.  Hydroelectric is unpopular and has limited growth potential.  Geothermal and tidal is also possible for very limited locations.

For obvious reasons of portability, energy for the transportation system is an even tougher issue.  Liquefied natural gas (fossil fuel) shows promise for surface transportation, particularly commercial vehicles.  Electrically powered vehicles, however, face two major challenges, power availability and storage.  No matter what type of battery is in a vehicle, it must be charged from some other generation source (see above).  Energy comes from the fuel in the tank, not the tank itself.  A battery is as useless as an empty gas tank until you until you fill it up.

Recent events with the Boeing 787 Dreamliner have brought to the forefront the limitations of high efficiency lithium ion batteries.  The future of electric automobiles is stalled until these limitations are overcome.  Although a major disruption for Boeing and the airlines, solution of the 787 battery issues will do far more for electric cars than it will for airplanes. 

The 787 can achieve most of its efficiency without lithium batteries.  They were chosen to help achieve the aggressive weight saving target that Boeing set for the Dreamliner.  Since there is no current alternative to jet fuel for airliners, efficiency must come from other places.  Specifically, it comes from increased engine performance and decreased aircraft weight.  Battery powered automobiles however, whether hybrid or fully electric, rely on safe, lightweight, and powerful batteries.  These batteries are mandatory, not just desirable.  If these batteries are deemed unsafe, the already anemic electric cars business is in serious trouble. 

Real technological advancement is difficult, messy and sometimes dangerous.  It includes huge financial investment, very smart people, research, failure, perseverance, and most of all patience.  It would be wonderful if it were as simple to realize a good idea, as it is to think of it.  Doing more with less (energy, human resources, side effects, environmental impacts, safety risks, etc.) is very difficult.  It’s not all butterflies, bunnies and unicorns.

We Must Learn From Others

For many years, while in the role of instructor/evaluator, I have used one principle facilitation technique to measure the progress of those I was working with.  If successful, they had to articulate how they created that successful outcome.  It is a version of the Socratic method.  Just pointing out errors, although common and easy to do, does not prepare anyone to be successful when they leave the training environment.  Nor does it facilitate effective self evaluation when students are on their own.  Knowing what works and how to apply that information is the key.

I try to avoid comparisons between the medical profession and air transportation.  Managing human health and providing safe transportation are very dissimilar pursuits.  However, there are some narrow areas that overlap.  One of these is error recognition and mitigation.  Air transportation, as I pointed out in a previous post, has been a leader in this area.  The medical profession, particularly in the hospital environment, has not done well with either threat management or error recognition and mitigation.

National Transportation Safety Board Chairwoman Deborah Hersman says back-to-back battery incidents aboard Boeing 787 Dreamliners in the United States and Japan are "an unprecedented event" and are a "very serious safety concern."   I believe the same focus that has been placed on the 787 safety issues should be directed at the medical community.  Possibly Dr. Regina Benjamin, the Surgeon General, could use a similar approach to addressing preventable deaths from medical errors and infections as her colleague Ms. Hersman.  This is not an attempt to point out areas of ineffective management, but rather an invitation to learn from others successes. 

The watershed accident for airborne electrical fires was Swiss Air 111 on September 2, 1998.  215 passengers and 14 crewmembers died when an electrical fault caused an uncontained fire on board the DC-10 aircraft and resulted in the unsurvivable crash off the coast of Halifax, Nova Scotia.  Everyone agreed that scenario was unacceptable.  The accident initiated profound changes in entertainment systems aboard airliners, as well as the associated  training, reporting and oversight.  The system asked, “What went wrong and how do we fix it so it doesn’t happen again?”  The aggressive approach to the elusive 787 battery problems is a direct result of that accident and those deaths.

 

In contrast, hospital acquired infections (HAI), are estimated by the CDC to cause about 100,000 deaths per year.  This figure, unfortunately, has been relatively constant for the last decade.  There is a very insensitive saying that speaks to this point. “If you’re not sick when you go in the hospital, you probably will be before you get out.”  Many of these HAI deaths could be avoided by simple, very low cost changes in hygiene practices.

In addition, there are other preventable medical errors, treating the wrong patient, treating the wrong body part, administering the wrong medication, surgical supplies left inside the body, etc. that are responsible for a significant number of fatalities.  It has been stated that if medical errors were classified as a disease, they would be the sixth leading cause of death in the U. S.  This scenario, I believe, is also unacceptable.

The resolution strategy has been known for some time, but remains elusive because it takes courage to “do it differently”.  The first step, a new mindset, is always the most difficult.  A paradigm shift in the culture of medicine is needed.  This is not new territory outside of medicine.  The aviation community went through a similar process before it could begin to effectively manage its own errors.  It is still difficult however.  Some airlines are remain hesitant to objectively look at their weaknesses as well as their strengths.

The Dean of the Harvard Medical School, Dr. Atul Gawande, spoke to error recognition and mitigation in his 2011 commencement address. He pointed out three skills the medical profession could focus on to reduce unnecessary patient deaths.  These are the same skills that have been adopted by effective airlines to address human error.

“For one, you must acquire an ability to recognize when you’ve succeeded and when you’ve failed…...”

“Second, you must grow an ability to devise solutions for the system problems that data and experience uncover.”

The third skill set Dr. Gawande described were the elements of humility, standardization and teamwork.

“They include humility, an understanding that no matter who you are, how experienced or smart, you will fail. They include discipline, the belief that standardization, doing certain things the same way every time, can reduce your failures. And they include teamwork, the recognition that others can save you from failure, no matter who they are in the hierarchy.”

Dr. Gawande didn’t reference him specifically, but these are the skills and values pioneered by Dr. Robert Helmreich, Founder and Director of The University of Texas HumanFactors Research Project.  The aviation community was an early adopter of that project.  Some in the medical community are starting to follow his recommendations.  His team’s work was the genesis of Threat and Error Management principles, the Aviation Safety Action Program (ASAP) and the Line Operation Safety Audit (LOSA) program.  These methodologies and programs have been very successful in reducing the negative consequences of human error in air transportation.  They have made a dramatic difference in the culture of the aviation community.  These results are a concrete validation of the message in Dr. Gawande’s speech.

To get better at anything people must acknowledge, accept, share, evaluate and address their errors. This must be done, not to reprimand, assign blame or to embarrass, but to humbly distill successful strategies from our human weaknesses.  We cannot wait until we learn everything on our own.  We must be willing to learn from the experiences of others as well.

Opportunity vs Outcome

I read a news article recently that initialed a very strong emotional response.  I was moved by the sadness of a missed opportunity.  The realization that so many times in life we are given an opportunity that if squandered will not be offered again.

Usually the football news this time of year has to do with coaches being let go and others being offered new positions.  Two teams are planning their strategy for the Super Bowl and the rest are lamenting their missed opportunities.  They can look forward to next year.  It could be said that no one has more regret this year Peyton Manning.  He and his Broncos thought they had a real shot at going to the big game.  But maybe next year for Manning and the Broncos, but not for another quarterback.

Two college quarterbacks were expected to be picked 1 and 2 in the 1998 NFL draft.  They both had been contenders for the Heisman Trophy.  The were both prolific passers and expected to be franchise players in the NFL.  Their stats were very close.  There was passionate discussion over who would be the number 1 pick.  The Indianapolis Colts held the first pick.  The San Diego Chargers traded their third overall pick, a future first round pick, a second round pick and three-time Pro Bowler Eric Metcalf to the Arizona Cardinals to improve their position.  No small price to pay for securing the second pick overall.

By the time of the draft the Colts had decided on Manning.  Although the Colts said it was not a significant factor in their final decision, the "interview no show" by the other quarterback was a harbinger of his work ethic.

Anyone who is at least familiar with football knows what kind of career Peyton Manning has had.  His name is all over the record books as well as a shoe in for a first ballot induction to the Hall of Fame.  The other quarterback, Ryan Leaf, had far from impressive career stats as well as a rocky relationship with coaches, teammates and the press.  The San Diego Chargers released him after only three wins in four years as a starter.  Leaf spent the remainder of his NFL career bouncing from Tampa to Dallas and finally Seattle.  During his brief career in the NFL, Leaf appeared in 25 games and made 21 starts. He completed 317 of 655 (48.4%) passes for 3,666 yards, with 14 touchdowns and 36 interceptions. In 2010, the NFL Network listed Leaf as the number one NFL quarterback bust of all time.  He was married briefly to a Chargers cheerleader.

After the NFL, Leaf returned to college and ironically earned a degree in Media Relations.  He took an unpaid job as a volunteer coach with West Texas A&M University until he was suspended and resigned over a drug related incident.  The former NFL quarterback's criminal career started in 2009 with an indictment on burglary and drug charges and because of other unlawful activities was sentenced in 2012 to the Montana correctional system.  Leaf was being held in rehab facilities until he violated the conditions of his sentence.  This past Thursday Ryan Leaf was transferred to Montana State Prison where he will finish out his sentence.

When he was drafted into the NFL what did Ryan Leaf visualize for his future.  Would he have ever dreamed on that day in April 1998 he would end up addicted, disgraced and in prison.  Neither Ryan Leaf nor Peyton Manning will be playing in this year's Super Bowl.  Peyton will be watching with his family from a luxury box at the stadium. Ryan, if he is allowed to, will be watching from prison.

No air crew ever pushes back from the gate with any other expectation than a safe arrival at the destination.  Fortunately, a safe arrival is almost always the case.  However, in rare instances, the outcome is not good.  The aircraft ends up broken and the passengers and crew are injured or killed.  A missed opportunity.  An opportunity that will not come again.

Opportunity is an invitation to make a difference.  On each flight, there is only one opportunity for the crew to achieve a safe outcome.  Each flight is its own opportunity, but just like all valuable opportunities, once lost cannot be recaptured.

Getting What You Want

With apologies to The Rolling Stones, you CAN get what you want.  We get what we want by actively creating a positive outcome or actively avoiding a negative one.  So I believe getting what you want is the true standard for the effectiveness of an organization.  And by that standard the air transportation industry is a model for effectiveness.  It gets what it (and the public) wants, safety.  Worldwide there were 425 fatalities in 2012 and 514 in 2011.  In the U. S. the 2012 numbers were 0 for airlines compared to 30 for rail and 54 for buses.

Again, the primary goal of the air transport industry is a safe operation.  A fundamental element of that industry is identifying and correcting problems before there is a catastrophic result.  I am, for the purposes of this discussion, quantifying a safe operation by the low numbers of injuries and fatalities experienced by the traveling public.  It is not the only measure, but a very objective one that I believe is appropriate here.  As long as there are still fatal accidents everyone associated with the air transportation industry has "an obsession with safety" so than not one fatality will have been in vain.   However, "blood response"  to an accident, as Staphan Barlay calls it is, is not what the air transportation industry wants.

I believe the events of the past couple weeks with Boeing's 787 Dreamliner are an excellent example of why the air transport industry is effective.  Unlike many other organizations today, air transportation system is willing to critically self evaluate.  This system includes operators, manufacturers, regulators, educators, engineers, pilot associations, investigators as well as independent safety experts is a system that is very introspective.  Also, the traveling public constantly holds this system's proverbial feet to the fire and the industry wouldn't have it any other way.  If there is a concern, from fatigue of a mechanical part to fatigue of a pilot, it gets attention.  The cost of inattention is too grave.

The 787 Dreamliner is a tremendous advancement in efficiency.  20% more economical for an already very efficient machine is huge.  An achievement that big requires all the systems and subsystems to be very high performance.  There is always a greater potential for problems when operating at high levels of performance.  Even with the most sophisticated design and testing protocols sometimes post production problems show up.  The 787 is most advanced airliner ever built, but certainly not the first with post production issues.  One of the most infamous examples was the design of the cargo door on one of the first wide body airliners.

From the very preliminary data, there appears to be a problem with the 787 batteries or their charging and distribution system.  This problem has manifest itself through the catastrophic overheating of the batteries on the Dreamliner.  There are two lithium batteries on the Dreamliner, one as a backup source for the ship's computers.  The other is for starting and control of the auxiliary power unit, a small turbine engine in the tail that provides electrical power when the aircraft engines are not running.

The FAA demonstrated some welcomed leadership with the 787 problems last week by issuing an emergency Airworthiness Directive grounding all 787 operations until the problem in the battery system is resolved.  Now the discussion of whether or not the airplane is safe to fly in its current configuration becomes academic and the industry can focus its attention on a solution.

I have no doubt that Boeing, the 787 operators and the NTSB, along with the three primary suppliers, Japan's GS Yuasa Corp, Securaplane Technologies Inc, a unit of Britain's Meggitt Plc, and France's Thales,  who make the batteries, charger and control systems respectfully, are all working round the clock to tackle this problem.  As this story plays out I am confident that we will learn of an incredibly sophisticated and collaborative process that will remedy the acute problems and result in an overall more reliable airplane.

Technology is not the only reason air transportation is so effective meeting its primary goal.  This industry was the first to courageously accept the inevitability of human error.  That is not a mindset easily embraced.  Air crews around the globe are now learning skills to identify and repair their own mistakes before they lead to a negative consequence.  Previously crews ignored or covered up their mistakes to avoid embarrassment or retribution.  Many disciplines have now followed aviation's lead in threat and error management, but others still cling to the old paradigm of, "good _______ (fill in the blank) don't make mistakes."  All humans make errors, the effective ones catch them before they cause a negative result..

Airlines get some pretty harsh criticism for their customer service, and at times well deserved.  The one thing that can't be argued however, is air transportation's record of safe travel. Air transportation is not perfect, but it is better than anything else out there.  Hats off to everyone who helps make it safe, one flight at a time.