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.

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.

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.

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 101^st 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