Did you know? If you were born on a US airliner in the 1980s and never got off, you’d only encounter your first fatal accident when you were 2300 years old, and you’d still have a 29% chance of surviving (Les Lautman, Safety Manager at Boeing, 1989).
The aviation industry isn’t perfect, and nor does it claim to be, yet on average, 100,000 scheduled flights traverse the globe everyday, safely and without incident. And that impressive track record stems from a healthy attitude to failure amongst the global aviation community – one worth exploring by any forward-thinking H&S professional.
Why flying became safer than ever
A pivotal incident in the evolution of aviation safety culture is that of the Kegworth air disaster in 1989, when a Boeing 737 crashed into the M1 during an emergency landing. The air accident investigation report shares alarming insight into behavioural flaws that needed urgent reform:
‘‘Although the cabin crew immediately became aware of heavy vibration at the onset of the emergency and three aft cabin crew saw flames emanating from the no. 1 engine, this information was not communicated to the pilots.”
Technology and mechanical quality has improved greatly since high-profile accidents like these in the 70s, 80s and 90s. But the most significant paradigm shift in aviation was recognition and acceptance that humans make mistakes.
We’ve moved a long way from the days when it was all the pilot’s fault, because after all, that attitude doesn’t help in the complex aftermath of a crash. Leaders realised that very early on, and steered aviation towards a culture where vigilant staff point out mistakes sooner, so they’re recovered from quicker.
Recognising flaws like those at Kegworth, aviation’s key success was to implement ‘Crew Resource Management’ (CRM) and invest heavily in investigation that reveals minor events and concerns from employees. Because, as Heinrich’s triangle shows, when people keep quiet, serious consequences often follow.
Let’s analyse the logic behind this
So, airline management knows humans make mistakes. Yet they’re still prepared to let their crews fly passengers around, knowing that they’ll inevitably make mistakes.
Because openly acknowledging this dilemma encouraged leaders to focus not on errors, but on what causes errors to occur, how to prevent circumstances happening in the first place, how to identify an error quickly when it does occur, and what to do to recover from it before it causes an incident or accident.
This proactive attitude developed task analysis in aviation that’s agnostic in the way it examines roles within the system.
What the aviation industry has effectively done is develop a worldwide ‘just culture’ that encourages people to report the minor issues so they can be learned from before they become the major issues. That translates into a fairly healthy, global reporting culture, and a cooperative attitude to continuous improvement.
People are no longer worried about saying they made a mistake because it’s openly acknowledged from the top that this is a fact of life; of course it does, people are humans. Beyond blame and recrimination there’s a drive to know what caused someone to make a mistake, and how other people can avoid making the same mistake – because they will.
What that says, culturally, is it’s no good punishing someone who errs, because as soon as you do, everyone else who does the same thing will keep it quiet, when really you want them to speak up.
The aviation industry acknowledges that failure is bigger than the individuals involved
A culture every organisation should aspire to
The aviation industry relies heavily on training to consolidate this attitude. It emphasises experience working in interdisciplinary teams, and breaking down organisational divisions for better communication and accountability.
Today, an experienced pilot of many years’ standing will typically thank the most junior member of cabin crew who questions his or her actions out of concern for safety. This is one of the core values of Tribe’s SUSA approach for effective conversations.
The reverse of this is a dictatorial approach from the top, which assumes every rule is perfect and everyone follows them to the letter. That’s not just unrealistic, it’s impossible and dangerous.
Strong leadership from management, and acceptance that human fallibility is natural was key to CRM’s success and the dramatic improvements in aviation’s safety record. More importantly though, was recognising that this isn’t a one-hit solution. Sending everyone in your business on a two-day ‘sheep dip’ is achievable in most organisations, but the cost associated with a rolling, career-long programme of crew and team resource management pulls hard on the purse strings.
This is the significant plunge that the aviation industry took many years ago. And when combined with improvements in automation, build capability of aircraft, and of course public scrutiny, it helped make 2016 one of the safest years in aviation history.
As you no doubt already know, results like this cost time, resources and money. Lots of money. But, as Stelios Haji-Ioannou, former owner of Easyjet once said: “If you think safety is expensive, try having an accident.”