Safe Is Not Safe Enough: We Must Change How We Search For Safety

Forty-three years ago I took my first flying lesson in a Cessna 150 that was already ancient at the time. As we lifted off the runway, I watched the tire spinning freely as we climbed away from the asphalt and I remember thinking, “This is magic!”

Thus began a life-time career in aviation as an Airline Transport Pilot rated instructor, air traffic controller in New York City, an accident investigator and safety evaluator for the FAA in Washington DC, and now a CEO of an international aviation firm. While part of me still believes there is magic in aviation, I also realize we must change how we examine accidents if we are to enhance safety further.

Aviation has seen tremendous improvements in safety over the years, but my experience tells me we have now evolved to a point where further gains in safety will require a different perspective – one that entails more balance in reporting and priorities, honesty in our analysis, and a stronger assessment of the role culture and the human element plays in an accident.

Since accidents have become so rare, when a major airline accident does occur, it becomes a worldwide media event with the investigation subject to the demands of social media and the insatiable 24-hour news cycle.

As this article is being written, the “black boxes” from the AirAsia crash in the Java Sea have just been recovered. While it will still be some time before we hopefully learn the cause of the accident, we are already seeing troubling speculation in various media sources that will influence how the accident is perceived.

During January, Indonesian authorities have been trying to recover AirAsia Airbus A320 that crashed into the Java Sea on 28 December

A recent article published by FlightGlobal, stated, “Calendar year 2014 has turned out to be the best 12 months ever for airline safety.”  We then learn that the assessment was based on “fatal accidents per 2.38 million flights” but excludes the Malaysia flight shot down over the Ukraine.

The article goes on to say, however, that while there were less fatal accidents, total fatalities increased from 281 in 2013 to 671 in 2014, an increase of 138%! The article attributes this to fewer accidents but bigger aircraft and I ask, “What message are we trying to send?”

There is generally universal acceptance that flying remains one of the safest forms of transportation today. But presenting data in this fashion leaves the reader, and especially the layperson, questioning the intent of the reporter. In a worst case scenario, the reader could perceive an effort to “spin” the data to sensationalize the story and that will do little to support the real goal of allowing accurate data to identify and drive the need for effective safety changes.

Another story published by “Newsweek” begins, “Indonesia’s Aviation Safety Rules Need Reforming,” and went on to state, “But anyone who knows aviation in Indonesia knows that the country has a horrific record for airplane accidents…” and then calls for stricter government controls. How the author came to that conclusion is unstated.

We forget that a complex investigation takes time and detailed analysis. Urgency can actually degrade safety if we take actions that are not well thought out, only to recognize newly created problems when we investigate the next accident.

What is missing in these articles, and other stories along similar lines, is the need for a realistic, fact-based reporting without speculation and more attention to a very critical part of the aviation system – humans and our respective cultures.

Now let’s discuss the role culture, government and regulations, and technology play on flight crews, and other parties’ performance.

There are some cultures that create an environment where it seems people may be afraid to use their better judgment for fear of retaliatory action by authorities.

For example, while we do not yet know what occurred in the cockpit of AirAsia, we can ask the question – with the benefit of 20-20 hindsight – if the crew had asked for a deviation from ATC due to severe weather, and that request was being delayed due to coordination, why wouldn’t they simply declare an emergency and divert to avoid the storm? Is it possible we may have “over-controlled” the emphasis on regulation and in the process limited the asset of experienced human judgment during a crisis? It’s a simple question, but anyone who has sat in the front left seat of an aircraft will tell you it’s not a simple answer.

Following most notable accidents there always seems to be calls for “the government” or “the regulator” to do something to fix the problem so it never happens again. It’s seen as a simple solution.

But there is rarely any one single event that triggers an accident and there is rarely just a single solution. More often than not, post accident regulatory changes will introduce additional complexities into the aviation system that risk setting the stage for future challenges, e.g., litigation from the Colgan crash and the impact on pilot shortages and training.

Safety is best maintained by discovering issues that increase the level of risk to an operation and fixing those issues, i.e., managing the risk before an accident occurs.

The adoption of formal risk management methodologies can serve as the gateway for future safety enhancements. Identifying the risks and hazards that impact safety will come from the people involved in using, running, and maintaining that system. They will see the problem first and are best suited to fix the problem – as long as they do not feel they are personally at risk for being honest, and susceptible to retaliation from employers or regulators or prosecutors. While oversight is important, there is little value to micro-management. The key is finding a realistic balance.

An environment whereby people feel comfortable in reporting safety events and even their own “honest mistakes” represents a “just culture”[1] environment that supports a positive safety culture as well. Creating that type of environment, while critical to enhancements within aviation safety, is not an easy road in many parts of the world or in organizations but even, “A journey of a thousand miles begins with a single step.”

Following major accidents, and again AirAsia presents another example, there are also calls for technology to solve the problem. But technology by itself cannot be the panacea for safety and ironically risks adding additional complexities that the human element is forced to deal with unless the human is better trained and skilled.

The growing trend of the influence of highly sophisticated automation on pilot performance is becoming obvious. The Colgan crash at Buffalo New York, Air France in the South Atlantic, Asiana’s B-777 crash at San Francisco, and probably AirAsia as well, all have a component of automation affecting the accident.

While we build more efficient aircraft comprised of complex computer systems, we may be building pilots who can push buttons better than any previous generation, but with little practical experience in the fundamentals of airmanship or worse – lack experience and judgment to see a pending problem before the warning light comes on.

Our course ahead to continue enhancing aviation safety will require the industry to take an honest look at where we are, what is important, where we want to go and how to get there. We may need to forsake our historical reactions of blaming the aircraft manufacturer, the pilots, the controllers, and pointing fingers and asking why the government/regulator didn’t prevent this. We also need to accept the fact that airlines are a business with a mission or purpose to make money – but do it safely. And we need to realize that, while the odds of being injured or involved in an aviation accident is extremely remote, there is still risk involved that we all have to manage.

We need to balance an organization and/or individuals’ responsibility for a duty of care, but that balance should also recognize that nobody ever goes to work with the intention of making a mistake and causing an accident.

We will never uncover the cause of an accident via sound bites, social media, or “talking heads.” It will only come through detailed and accurate analysis of a new generation of issues – some technical, some political, some social, and all human.

We are always going to have to begin an accident investigation with the search for “what happened,” since that is the foundation to answer the key question, “why did it occur?” But the journey to seek safer skies will need to be based on holistic solutions that better understand and include the human element and our cultures – and address the challenges to making effective change. When we reach that zenith we will bring back the magic in aviation.

 

[1]Just Culture is defined as «a culture in which front-line operators and others are not punished for actions, omissions or decisions taken by them which are commensurate with their experience and training, but where gross negligence, willful violations and destructive acts are not tolerated,” and now reconised by ICAO and the European Commission. For further details see www.eurocontrol.int/articles/just-culture.