The Power of Influence

In a recent episode of the Big Bang Theory, Bob Newhart makes a guest appearance as an elderly scientist/TV personality.   His character hosted a children’s science show that Sheldon, Jim Parsons, and Leonard, Johnny Galecki, obsessively watched as young boys.  When Professor Proton, Bob Newhart, laments his legacy, Sheldon and Leonard give him credit for inspiring them to become ground-breaking physicists.   Sheldon tells Prof. Proton, “A generation of scientists are standing on your shoulders.”  I am sure I’m not the only one who sees the irony that the relationship being acted out by Prof. Proton, Sheldon and Leonard is one that took place in real life between Newhart, Parsons and Galecki.  Bob Newhart is a legend.  He has been the inspiration for many famous comedians and ensemble actors.  His TV shows have helped define the standard by which all sitcoms are judged.  The Big Bang Theory is now just as popular as Newhart’s shows for the same impeccable comedic timing and the humorous relationships of quirky characters.  Life imitating art imitating life.

How do we know what influence we may have overs, whether they be in the next generation or our own?  The answer is, “We don’t.”  But that is just the point.  Since we do not know, we must act as if we do.  When we are given an opportunity to influence others we must exercise that responsibility deliberately and with a purpose.  This is especially true in the area of our chosen profession.

A professional is one who is accepted as very skilled or expert at a given activity.  Usually those professionals who are recognized among their peers as having influence are not in leadership roles.  Their influence comes from how they perform at their job.  Airline Captains have a very influential role in their profession. Because of the unique interface of man and machine, the airline Captain must have effective skills handling the crew as well as the aircraft.  When they are in command, Captains set a tone on the flight deck that will establish the relationship they will have with their crew.    How the Captain handles the aircraft will establish his or her performance expectations.   The Captain who builds effective relationships as well as demonstrates strong airmanship skills is the one who has influence.

To have influence is one of the greatest honors that can be given a professional.

Hours of Boredom........

This is my 50^th post on Flying The Backside.  That’s not much of an accomplishment for a real writer, but for a pilot like me it is quite a milestone.

In its brief few years the blog has evolved, but the objective hasn’t changed.  From the outset I wanted to initiate a dialog among aviation professionals.  I hoped that my statements, questions and opinions would lead readers to make comments both in agreement and opposition.  I endeavored to have an online facilitation of topics relevant to human factors in aviation.

I would like to thank everyone who has spent their valuable time reading and considering my thoughts.  Also, special gratitude goes to those who felt comfortable making comments.

The origins of this quote cannot be verified, but it is well known and often used to described aviation.  “Hours and hours of boredom punctuated by moments of sheer terror.”  Moments of “sheer terror” might be hyperbole, but it makes the point.  Because during the moments of “sheer terror” it is difficult for aircrews to immediately react with effective plans unless those scenarios have been considered in advance.  Checklists and procedural guidance can help, but the most effective technique crews can use is to consider these emergency and non-normal scenarios in advance.  For the same reasons recurrent training events are more suited to practicing and reinforcing potential strategies than an opportunity to begin considering these events.

My hope is still that Flying The Backside would initiate discussions involving the human factors that influence aviation safety.  As a community we have a vast amount of knowledge and experience.  Informally sharing this information and related topics can only have a positive effect on aviation safety.

Thank you and I look forward to your thoughts and insights.

A Rose By Any Other Name……

When things appear to be different, that difference may be more a matter of perspective than difference. In fact the two might be the same as demonstrated in the iconic Checkerboard Illusion, by Edward H. Adelson

There are two perspectives in the aviation safety management universe.  The angst between these two camps is not as passionate as that between Shakespeare’s Montagues and Capulets, but like these two families they are really not that different.  

The first camp says that the way to a safe operation, i.e. risk management, is to plot the coordinates of computed probability and severity on a “risk” graph and decide if the result is in the “green” or safe zone. This is known as a risk assessment process.   The risk assessment provides both the evaluation of the risk as well as an opportunity to look for ways to adjust or manage the probability and/or severity to a more “acceptable” value.

 

The second camp says that the way to a safe operation is to identify and manage threats to drive the actual probability toward zero while for operational purposes, assuming there will be an occurrence.  Then evaluate whether, if there is an occurrence, are there are measures available that will allow the airplane land safely. 

Both of these groups are trying to reach that coveted “green zone” that signifies a safe operation.  Aviation is inherently dangerous and therefore risky by nature.  I’ve talked about this before. We cannot eliminate risk in aviation.  Risk in aviation can only be managed.  How then, can it be “managed”?  How will we know when risk has been managed effectively?  Hint, the outcome is never in doubt.

This take us back to the matrix.  The lower left block, 1 on the probability/severity scale, is the one we’re looking for.  Unfortunately, zero does not appear in the matrix.  How will we know if we are in that box?

Those who see risk on the probability/severity graph would endeavor to introduce elements into the operation like procedures and technology as well as training to lower the probability of the risky event or condition.  In addition they would like to introduce similar elements that avoid or neutralize elements of the operation to decrease the severity of a given condition.  This was the motivation behind Safety Management Systems, SMS.

 

We have to decide what risk is acceptable and what is not. What methodology do we use to determine acceptable risk?  FAA Advisory Circular 120-92A, Safety Management Systems for Aviation Service Providers, gives us some guidance.  However, the framework and structure outlined in the Advisory Circular are mainly targeted at the organizational level.  What about at the crew level?  Whereas the traditional risk assessment process relies heavily on a high level of compliance and performance, reality has shown that a successful outcome is more dependent on awareness, analysis and decision making. Is SOP compliance enough to mitigate risk?  Is 100% crew compliance any more achievable than attaining zero risk?  What is the minimum level of human performance necessary for a risk assessment to be valid?   

  

This is where Helmreich, Merritt, Klinect, et al were way ahead of their time.  They asked probing questions and came to the following conclusion.  Organizational risk management, in the form of standard operating policy, is not enough.  It is only half of the answer.  Total risk assessment and management must include the crew as well.  In a dynamic environment like aviation, policy and procedure provide a solid foundation and provide and excellent framework, but are they enough?  What role does culture play in risk management?  How can risk truly be managed to an acceptable level if human error is not included in the equation?

For a crew in an operational environment, I believe the boundaries of acceptable risk for any condition are defined by a probability as low as practicable and a degree of severity that will, with reasonable mitigation, assure a safe outcome.

This is the rationale for Threat and Error Management, TEM.  It is the link between organizational risk management, SMS and crew performance.  TEM recognizes the strengths and the weaknesses of human performance within the overall safety management system.  Each risk can be expressed by a set of unique threats.  Threats are commonly described as operational events that occur outside the influence of the crewmember, increase operational complexity and/or require crewmember attention to maintain safety margins.  When these threats are effectively managed or mitigated, the risk may be considered acceptable.  Weather events are an excellent example.  In cases when the threats of the condition can be managed to a safe outcome the risk is acceptable.  When they cannot be managed or there is doubt, the risk is unacceptable. 

There are many components to an effective management or mitigation strategy.  The primary and most important component is appropriate compliance with SOP.  It is the soft skills of situation awareness, leadership, decision making, communication, monitoring as well as workload and automation management that allow crews to effectively apply SOPs to the dynamic situation.

As previously mentioned, a major weakness of the traditional probability/severity risk management paradigm is the component of human error.  Errors are commonly referred to as crewmember actions or inactions that lead to deviations from crew or organizational expectations or reduce safety margins.  Errors may occur from spontaneous human error with no threat present or mismanagement of an existing threat.  The foundational strength of error management is the acceptance and preparedness for crew error.  It is the recognition and ownership of the inevitability of humans to make errors.  Therefore, the goal is to identify and mitigate errors before there is a negative consequence rather than to naively assume an unrealistic and unachievable level of human performance.

Like the overwhelming love that Romeo and Juliet shared, so do Risk Assessment and Threat and Error Management share the bond of safety.  The young couple agonized over the barriers of their surnames.  What tragedy might have been averted had one not been named a Capulet and the other a Montague?

JULIET

O Romeo, O Romeo! Wherefore art thou Romeo?

Deny the father and refuse thy name;

Or, if thou wilt not, be but sworn my love.

And I’ll no longer be a Capulet.

ROMEO (Aside)

Shall I hear more, or speak of this?

JULIET

‘Tis but thy name that is my enemy;

Thou art thyself, though not a Montague.

What’s a Montague? It is nor hand, nor foot,

Nor arm, nor face, nor any other part

Belonging to a man.  O, be some other name!

What’s in a name?  That which we call a rose

By any other name would smell as sweet;

So Romeo would, were he not Romeo call’d

Retain that dear perfection which he owes

Without that title.  Romeo, doff thy name,

And for that name which is no part of thee

Take all myself.

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.