Etiquetado: aviation accidents
A comment about a good reading: Air Safety Investigators by Alan E. Diehl
Some books can be considered as a privilege since they are an opportunity to have a look at an interesting mind. In this case it’s the mind of someone who was professionally involved in many of the air accidents considered as HF milestones.
The author, Alan Diehl, has worked with NTSB, FAA and U.S. Air Force. Everywhere, he tried to show that Human Factors had something important to say in the investigations. Actually, I borrowed for my first sentence something that he repeats once and again: The idea of trying to get into the mind of the pilot to know why a decision was made.
Probably, we should establish a working hypothesis about people involved in an accident: They were not dumb, nor crazy and they were not trying to kill themselves. It would work fine almost always.
Very often, as the author shows, major design and organization flaws are under a bad decision driving to an accident. He suffered some of these organization flaws in his own career by being vetoed in places where he challenged the statu quo.
One of the key cases representing a turning point for his activity but, regretfully, not for Aviation Safety in military environments happened in Gulf war: Two F15 planes shooted two American helicopters. Before that, he tried to implement CRM principles in U.S. Air Force. It was rejected by a high rank officer and, after the accident, they tried to avoid any mention of CRM issues.
Diehl suffered the consequences of disobeying the orders about it as well as whistle-blowing some bad Safety related practices in the Air Force. Even though those practices represented a big death toll that did not make a change.
As an interesting tip, almost at the end of the book, there is a short analysis of different reporting systems, how they were created and the relationship among them. Even though, it does not pretend to be an important part in the book, it can be very clarifying for many people who can get lost in the acronyms soup.
However, the main and more important piece of the book is CRM related: Diehl fought hardly to get CRM established after a very well-known accident. It involved a United DC-8 in Portland, who crashed because it ran out of fuel while the pilot was worried about the landing gear. That made him delay the landing beyond any reasonable expectation.
It’s true that Portland case was important as well as Los Rodeos and Staines cases were also very important as major events to be used as inputs for the definition of CRM practice. However, and that is a personal opinion, something could be lost related with CRM: When Diehl had problems with Air Force, he defended CRM from a functional point of view. His point, in short, was that we cannot admit the death toll that its absence was provoking but…is CRM absence the real problem or does it have much deeper roots?
CRM principles can be hard to apply in an environment where power distance is very high. Once there, you can decide if a plane is a kind of bubble where this high power distance does not exist or there is not such a bubble and, as someone told me, as a pilot I’m in charge of the flight but the real fact is that a plane is a barracks extension and the higher rank officer inside the plane is the real captain. Nothing to be surprised if we attend to the facts under the air accident that beheaded the State in Poland. “Suggestions” by the Air Force chief are hard to be ignored by a military pilot.
Diehl points out how in many situations pilots seem to be inclined to play with their lives instead of keeping safety principles. Again, he is right but it can be easily explained: Suppose that the pilot, in the flight that crashed with all the Polish Government onboard, rejects the “suggestion” and goes to the alternate airport. Nothing should have happened except…the outcome for the other option is not visible and everyone should find reasons to explain why the pilot should have landed in the place where he tried to do it. His career should be simply ruined because nobody would admit the real danger under the other option.
Once you decide, it’s impossible to know the outcome of the alternate decision and that makes pressure especially hard to resist. Then, even if restricted to the cockpit or a full plane, CRM principles can be hard to apply in some organizations. Furthermore, as Diehl suggests in the book, you can extend CRM concepts well beyond the cockpit trying to make of it a change management program.
CRM, in civilian and military organizations, means a way to work but we can find incompatibilities between CRM principles and organizational culture principles. Management have to deal with these contradictions but, if the organizational culture is very strong, it will prevail and management will not deal with the contradictions. They will simply decide for the statu quo ignoring any other option.
Should have CRM saved the many lost lives because of its absence? Perhaps not. There is a paradox in approaches like CRM or, more recently, SMS: They work fine in places where they should be less required and they don’t work in places where its implementation should be a matter of urgency. I’m not trying to play with words but establish a single fact and I would like to do so with an example:
Qantas, the Australian airline, has a highly regarded CRM program and many people, inside and outside that Company, should agree that CRM principles meant a real safety improvement for the Company. Nothing to oppose but let me show it in a different light:
Suppose for a moment that someone decides removing all the CRM programs in the world because of…whatever. Once done, we can ask which companies should be the most affected because of that. Should be Qantas among them? Hard to answer but probably not. Why?
CRM principles work precisely in the places where these principles were already working in the background. Then, CRM brings order and procedures to a previous situation that we could call “CRM without CRM program”, for instance, a low power distance where the subordinate is willing to voice any safety concern. In this case, the improvement is clear. If we suddenly suppress the activity, the culture should keep alive these principles because they fitted with that culture from the very first moment and before.
What happens when CRM principles are against organization culture? Let me put it in short: Make-up. They will accept CRM as well as they accept SMS since they both are mandatory but everyone will know the truth inside the organization. Will CRM save lives in this organizations, even if they are enforced to implement it?
A recent event can answer that: Asiana accident in San Francisco happened because a first officer did not dare to tell his captain that he was unable to land the plane manually (of course, as usual, many more factors were present but this was one of them and extremely important).
Diehl clearly advocates for CRM and I believe he is right and with statistical information who speaks about safety improvement. My point is that improvement is not homogeneous and it happens mainly in places that were already willing to accept CRM principles and, in a non-structured way, they were already working with them.
CRM by itself does not have the power to change the organizational culture in places that reject its principles and the approach should be different. A very good old book, Critical Path Renewal by Beer, Eisenstat and Spector explains clearly why change programs don’t work and they show a different way to get the change in organizations who reject it.
Anyone trying to make a real change should flee from change programs even if we agree with the goals but one-size-fits-all does not work. Some principles, like the ones under CRM or SMS, are valid from safety point of view but, even though everyone will pay lip service to the goals, many organizations won’t accept the changes required to get there. That is still a hard challenge to be completed.
Published originally in my Linkedin profile
«Seconds to Disaster» by Glenn Meade and Ray Ronan
When I read my doctoral dissertation -you can find two versions in the blog frame depending of your kind of interest: Aviation or Organizational Studies- I remember especially one of the persons who had to evaluate it, Secundino Valladares. He said: «Now, I’m sure that I will never fly again». I cannot blame him: To justify every finding, I put two or three paragraphs, extracted from official reports about major Aviation accidents. It was quite easy to reach that conclusion. After reading the book by Meade and Ronan, I have started to think of myself as a soft nun, regarding the kind of things they bring to the discussion.
For instance, the existence of compromises between regulators and main manufacturers is crystal-clear and there are many facts that can show how the European regulator does not look with the same eyes at both, Boeing and Airbus, and the same can be said about FAA but, of course, in the opposite side. Even though, the chapter that the authors devote to Boeing 737NG shows something far beyond a «friendly eye». Nothing new; some of us are old enough to remember what happened with DC-10 and how 325 avoidable deaths (Turkish Airlines 981) were required to fix a problem that was previously known. The authors speak too about AF447 -you will find in this blog several posts dealing with AF447- and, for a moment, I had the feeling of not being alone with my conclussions about this case: The stamp «Lack of Training» is very comfortable to close a report avoiding entering in design issues. However, this stamps does not answer the main question: If that is true…why did you have people lacking training to fly a big plane over Atlantic Ocean? We can go beyond: Is that a training practice by Air France or is it shared worldwide? Still, we can go beyond: Is it possible, due to design complexity, provide pilots and engineers with the training level that they could require under an extreme situation? Once we get here, we could be around the root of the problem: Profit aimed design.
A few days ago, I published something about how average passengers boarding a twin plane for a long-haul trip does not know what are the rules: He does not know that, in the event of an engine-stop, the plane is certified to fly more than 5 hours from the nearest airport with only one engine working and full of passengers. This and many of the things that the authors of «Seconds to Disaster» say are unknown to the flying public. Perhaps, this is the first thing to change if we want to change something.