Let's Try Looking At The Forest Instead Of The Trees

I have really struggled this week to organize my thoughts on the Asiana 777 tragedy at SFO last Saturday.  Sadness with the loss of life of course, was my first reaction.  I was awed at the scenes from amateur video showing the evacuation where lives were saved as well as lost.  I am frustrated that once again, experienced professional airmen with the best intentions were unable to prevent this accident.

The NTSB team that is investigating this accident will determine the factors, the set of threats if you will, that led to this fatal, hull loss.  They ultimately will determine the probable cause and contributing factors.  We do know that the aircraft was in an undesired state from which the crew could not or did not recover, but that is just the starting point.

It has been said that there are three crucial points in the evolution of an accident.  They are the point at which an accident becomes possible, the point when an accident becomes probable and then the point where an accident is inevitable.  Avoidance or recovery by the crew is possible, but becomes increasingly more difficult until the third point is reached. 

The analysis of approach and landing accidents resulting in a runway excursion has shown that unstable approaches are a major contributing factor.  In a majority of these accidents, absence of a go around or missed approach was the point at which probable became inevitable.

It is far too early in the investigation of Asiana 214 to discuss or speculate what factors, i.e. threats and errors, contributed to the accident.  It is certainly appropriate, however, to discuss the psychological factors that go into the critical decision to execute or not execute a go around.

The psychology of a go around is a profound and complex topic.  It would appear to be very simple, particularly in light of the fact that most operators and regulators have very clear procedural guidance on the continuation of an unstable approach.  Why then, do the statistics show that only a small number of unstable approaches by scheduled carriers result in a go around?  FOQA (Flight Ops Quality Assurance) recorders, LOSA (Line Operational Safety Audit) observers as well as anecdotal data all confirm the same paradigm.  Airline pilots fly very few (far less than 5%) approaches that would be classified as unstable.  However, of that small number of unstable approaches, very few go-arounds are performed.  It is this conundrum that defines the psychology of a go around.

Why is the continuation of an unstable approach to a landing such a common occurrence?  The same pilots who land out of an unstable approach would never consider continuing below a decision altitude on an instrument approach.  Years ago one would occasionally come across a “cowboy pilot” that would duck under, but I haven’t heard of that in many years.  Why do pilots treat the bottom line or decision altitude on an instrument approach differently than the stabilized bottom line, usually 500’ AGL, on a visual approach?  Is it because we have not “given ourselves emotional permission” to go around?  Is it just a matter of ego or saving face? Is it the same mental process that allows drivers to be ok with talking on a mobile phone because they have “gotten away” with it in the past?  Is it because pilots see their immediate and specific goal as landing vs. the general objective of maintaining a safe operation?  Is it because the crew does not think a go around is necessary at that point to remain safe?

I am not a psychologist and I struggle to completely resolve these questions in my own mind.  I could not begin to answer them for anyone else or the pilot population as a whole.  I wonder what would be the effect of making a go around the default termination of a visual approach like that of an approach in instrument conditions.  We are always emotionally prepared as well as mentally committed to a missed approach in low visibility.  Why can’t we be as prepared and committed to a go around on a visual approach?

Accident investigation data has shown that policy and procedure alone are not adequate to address this perplexing issue.  The data has also shown that non-compliance is seldom an overt act, but rather the result of some distraction or other operational threat. In fact, sometimes the rigid or compulsive pursuit of procedural compliance becomes the distraction.  It’s the classic case of getting lost in the forest because of all the trees.  The points where an accident or incident progresses from possible to probable to inevitable are not objective, but rather exist subjectively in the mindset of the crew. 

Are we, individually and collectively, prepared and committed to execute an unnecessary go around to avoid the point where probable becomes inevitable?  

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.