A hard look at risk man­age­ment in avi­a­tion

Flying - - CONTENTS - By John King

“There can be no com­pro­mise with safety.” “Safety is our No. 1 pri­or­ity.” You hear these kinds of quotes all the time from well-mean­ing peo­ple — very of­ten peo­ple like the sec­re­tary of trans­porta­tion or the ad­min­is­tra­tor of the FAA.

The as­ser­tions are meant to be com­fort­ing, and they are — es­pe­cially af­ter a crash. They as­sure the pub­lic of the firm re­solve by peo­ple in power to do bet­ter. The prob­lem is these words aren’t, and can’t be, true.

You can’t start an engine with­out com­pro­mis­ing safety. If safety were our No. 1 pri­or­ity, we’d never move an air­plane. Clearly, go­ing some­where is in it­self a demon­stra­tion that mov­ing the air­plane ranks ahead of safety. It would al­ways be safer to stay put. These lit­tle in­tel­lec­tual dis­hon­esties tend to end dis­cus­sion and sub­sti­tute for gen­uine anal­y­sis on the sub­ject.

It can be dis­com­fort­ing to talk openly and hon­estly about safety, so we of­ten make false as­sur­ances and oth­er­wise de­ceive ourselves. For in­stance, we usu­ally talk about safety as if it were an ab­so­lute. But ab­so­lute safety is an im­pos­si­bil­ity. In re­al­ity, safety is rel­a­tive. Ev­ery ac­tiv­ity has a greater or lesser de­gree of risk as­so­ci­ated with it. Still, when some­one de­parts on a trip, we usu­ally say, “Have a safe trip,” as a po­lite ex­pres­sion of good­will. We say this when we know hav­ing a gen­uinely safe trip is lit­er­ally im­pos­si­ble.

Not only do we find it un­com­fort­able to ad­mit to ourselves that we can never achieve ab­so­lute safety, but we some­times ut­terly lie to ourselves not to have to face re­al­ity about safety. Gen­eral avi­a­tion pi­lots fre­quently used to tell them­selves, and their pas­sen­gers, that the drive to the air­port was the most dan­ger­ous part of the trip. They wanted to be­lieve that fly­ing their pis­ton-engine gen­eral avi­a­tion air­plane was safer than driv­ing. When it be­came known that the fa­tal­ity rate per mile in a gen­eral avi­a­tion air­plane was seven times that of driv­ing, they had a very hard time ac­cept­ing that re­al­ity. (On the other hand, for var­i­ous rea­sons, travel on the air­lines is in fact seven times safer than travel on the roads.)

Some­times our self-de­cep­tion on the sub­ject of safety re­flects wish­ful think­ing. Af­ter a se­ries of com­muter air­line crashes, the ad­min­is­tra­tor of the FAA at­tempted to man­date one level of safety for lit­tle air­planes as well as big air­planes. The prob­lem is that it is not pos­si­ble for a small air­plane to be as safe as a Boe­ing 747. Safety equip­ment adds weight. A lit­tle air­plane can’t be ex­pected to carry the weight of the safety pro­vi­sions of a 747 jet air­liner. Plus, safety is ex­pen­sive. A lit­tle air­plane can’t af­ford the cost of safety equip­ment the way a big­ger plane can. But who wants to

tell that to some­one about to fly in a smaller air­plane?

On the other hand, when noted Aus­tralian thought leader and avid pi­lot (weight-shift trikes, sin­gleengine air­planes, he­li­copters and jets) Dick Smith was chair­man of the Aus­tralian Civil Avi­a­tion Safety Author­ity, he steered peo­ple away from disin­gen­u­ous talk about safety. He shocked peo­ple by talk­ing about “af­ford­able safety.” His point was that when safety be­comes too ex­pen­sive there can be a net re­duc­tion in safety. When ex­ces­sively ex­pen­sive safety mea­sures are man­dated, the cost of fly­ing goes up. At some point, peo­ple take less-safe sur­face trans­porta­tion in­stead, and fa­tal­i­ties rise.

An­other prob­lem with the way we talk about safety has to do with how safety-re­lated ad­vice is usu­ally given. It of­ten pro­vides in­ad­e­quate guid­ance. Safety ad­vice usu­ally takes a neg­a­tive ap­proach, stat­ing what you can­not do, rather than fo­cus­ing on pos­i­tive things you should do. In many cases, it is lim­ited to a hodge­podge of rules and say­ings. The rules and say­ings might all be good, but they are not ad­e­quate be­cause they fail to pro­vide the big pic­ture and struc­ture.

Safety ad­vice can even gen­er­ate re­sis­tance. It can be preachy — tak­ing on an off-putting air of smug­ness and su­pe­ri­or­ity. It is not un­com­mon for ad­vis­ers to sug­gest that some­one does not ex­er­cise proper “judg­ment” or “aero­nau­ti­cal de­ci­sion-mak­ing.” This comes across as a vague, de­mean­ing crit­i­cism, but once again, with very lit­tle use­ful guid­ance.

So what is the al­ter­na­tive? We need to change our vo­cab­u­lary. In nearly ev­ery case, it is more in­sight­ful and help­ful to talk about risk man­age­ment than safety. The con­cept of risk man­age­ment sug­gests a proac­tive habit of iden­ti­fy­ing risks, as­sess­ing them and ex­plor­ing mit­i­ga­tion strate­gies for them. The words risk man­age­ment pro­vide much-needed guid­ance about what peo­ple should do to get a safer out­come, in a way that the con­de­scend­ing crit­i­cisms, and em­pha­sis on “safety,” do not.

One of the prob­lems about the way we some­times use the word safety is that if some­one wants some­thing done a cer­tain way, they can of­ten just sim­ply trot out the word safety, or for that mat­ter, se­cu­rity, and get carte blanche agree­ment with lit­tle anal­y­sis. But the words risk man­age­ment re­quire a more thought­ful dis­cus­sion — in­clud­ing, in most cases, iden­ti­fi­ca­tion and as­sess­ment of the risks and the ap­pro­pri­ate­ness of the mit­i­ga­tion strate­gies.

When an avi­a­tion tragedy oc­curs, rather than try­ing to re­as­sure and com­fort peo­ple by promis­ing things that are not pos­si­ble, avi­a­tion lead­ers should say, “Our job is to un­der­stand the risk-man­age­ment fail­ures that al­lowed this to hap­pen and see that they do not oc­cur again.”

Much to its credit, the FAA’s Flight Stan­dards Ser­vice has em­braced “risk-based de­ci­sion-mak­ing” as one of its core val­ues. The idea is that in this busi­ness of cre­at­ing rules about how avi­a­tion should be run, they will now think in terms of the risks of an ac­tiv­ity.

Ev­ery safety mea­sure has a trade­off in loss of fun and util­ity. When risk-based de­ci­sion-mak­ing is a core value, that trade-off will be taken into con­sid­er­a­tion dur­ing rule-mak­ing.

The good news is that much of the avi­a­tion com­mu­nity is now fo­cused on risk man­age­ment rather than safety. First, flight schools are mov­ing to­ward sce­nario-based train­ing to help pi­lots learn risk man­age­ment. The idea is to give a learn­ing pi­lot the tools to ha­bit­u­ally iden­tify, as­sess and mit­i­gate risk. Then, when that pi­lot is eval­u­ated dur­ing the prac­ti­cal flight test, the FAA’s new Air­man Cer­ti­fi­ca­tion Stan­dards (ACS) re­quire risk man­age­ment to be eval­u­ated in ev­ery area of op­er­a­tion.

Martha and I have been pro­mot­ing straight talk about safety for years. We fi­nally fig­ured we must be mak­ing progress when an at­tendee came up to us af­ter a talk and said, “Have a rel­a­tively safe trip home.”

Lots of plan­ning went into fly­ing and stay­ing at an air­port that was in the eclipse's path of to­tal­ity.

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