Innovation and Consolidation in Aviation

Selected Contributions to the Australian Aviation Psychology Symposium 2000

Peter Pfister, Graham Edkins

• Publisher: Routledge
• Year: 2017
• Print ISBN:
  9780754619994
• eBook ISBN:
  9781351927406
• Topic: Technology & Engineering
• Subtopic: Business General
• Index: Technology & Engineering

This unique book expands the contribution of aviation psychology and human factors to the aviation industry within the Asia Pacific region, with participation from many other parts of the globe, and key local and international experts, developing the safety, efficiency and viability of the industry. It is a forward-looking work, providing new strategies for psychology and human factors to increase the safe and effective functioning of aviation organisations and systems, pertinent to both civil and military operations. This is the formal refereed proceedings of The Fifth Australian Aviation Psychology Symposium, Manly Beach, Sydney 2000. The symposium had a diverse range of contributions and Development Workshops, bringing together practitioners from aviation psychology and human factors, flight operations management, safety managers, pilots, cabin crew, air traffic controllers, engineering and maintenance personnel, air safety investigators, staff from manufacturers and regulatory bodies, and applied aviation industry researchers and academics. This book will be of interest to anyone involved in human factors, safety systems or aviation psychology within both the civil and military aviation industry.

Chapter 1
Heroic Compensations: The Benign Face of the Human Factor

James Reason

Department of Psychology, University of Manchester, UK

Introduction

The human factor gets a bad press. There are two approaches to studying human performance in high-technology hazardous systems: one involves the ‘fly-on-the-wall’ observation of normal activities; the other is triggered by the occurrence of an adverse event. An ‘event’ is something untoward that disrupts the flow of normal or intended activities and which may, and often does, have harmful consequences. In Human Factors research, at least, there can be little doubt that the dominant tradition is the event-dependent one. Such analyses focus upon the errors and violations that either constitute or contribute to an event. The worse the event, the more intensive the investigation of the preceding decisions and actions. As a result, we have learned a good deal about the varieties of unsafe acts and, to a lesser degree, we know something of the circumstances that can provoke and shape them (Hollnagel, 1993; Reason, 1990).

Unfortunately, this has established a very biased view of the human factor as something that is causally implicated in the large majority of bad events (Hollnagel, 1993). To compound the problem further, stating that people make errors is probably one of the least interesting observations about the human condition on a par with declaring that we breathe oxygen and will some day die. Such information is undoubtedly important, but hardly newsworthy. Nonetheless, errors are sufficiently uppermost in the minds of the managers of hazardous technologies that they often regard the main goal of safety management as the elimination of human fallibility rather than the avoidance of its damaging consequences (Amalberti & Wioland, 1997).

So, if human fallibility is a mere truism, what is there that is really interesting about human performance? The answer, I believe, lies on the reverse side of the coin. As operators of complex systems, people have an unmatched capacity to adapt and adjust to the surprises thrown up by a dynamic and uncertain world. This includes the often remarkable ability to compensate for their own errors. Making errors is a fact of life, but recovering from them particularly when these recoveries involve heroic improvisations is quite another matter. The story of the ‘Gimli glider’ will serve to illustrate this point.

The Gimli Glider

On July 23, 1983, a Boeing 767 aircraft en route to Edmonton from Ottawa ran out of fuel over Red Lake, Ontario, about halfway to its destination. The reasons for this were a combination of inoperative fuel gauges, fuel loading errors and mistaken assumptions on the part of the flight crew. These errors and system failures were dealt with at length in the 104-page report of the Board of Inquiry (Lockwood, 1985). Only three paragraphs were devoted to the most extraordinary feature of this event: the forced landing at Gimli, a disused military airstrip, from which all 61 passengers and eight flight crew walked away unharmed and the aircraft was fit for service after relatively minor repairs.

When the second engine stopped, the aircraft was at 35,000 feet and 65 miles from Winnipeg. All the electronic gauges in the cockpit had ceased to function, leaving only stand-by instruments operative. The First Officer, an ex-military pilot, recalled that he had flown training aircraft in and out of Gimli, some 45 miles away. When it became evident that they would not make it to Winnipeg, the Captain, in consultation with Air Traffic Control, redirected the aircraft to Gimli, now 12 miles away on the shores of Lake Winnipeg. The report continues as follows:

Fortunately for all concerned, one of Captain Pearson’s skills is gliding. He proved his skill as a glider pilot by using gliding techniques to fly the large aircraft to a safe landing. Without power, the aircraft had no flaps or slats to control the rate and speed of descent. There was only one chance of landing. By the time the aircraft reached the beginning of the runway, it had to be flying low enough and slowly enough to land within the length of the 7,200 foot runway. As they approached Gimli, Captain Pearson and First Officer Quintal discussed the possibility of executing a side-slip to lose height and speed close to the beginning of the runway. This the Captain did on the final approach and touched down within 800 feet of the threshold. (p. 29)

The last laconic sentence is a masterpiece of understatement. It is unlikely that either Boeing or Captain Pearson’s employers had ever imagined the side-slip manoeuvre being applied to a wide-bodied jet airliner. As it turned out, however, it was almost certainly the only way that the aircraft could have made a safe landing under those circumstances. This was heroic improvisation at its most inspired.

Theoretical Framework

The literature provides relatively little in the way of theoretical guidance when it comes to understanding and facilitating these remarkable adaptations. Most safety-related studies have focussed upon identifying those factors that create moments of vulnerability rather than elucidating the nature of resilience. The two notable exceptions are, firstly, the observation-based analyses of high reliability organisations, or HROs (Weick, Sutcliffe, & Obstfeld, 1999); and, secondly, the more person-oriented work on mental readiness in the achievement of sporting and surgical excellence (Orlick, 1990). Although these two research areas derive from different disciplinary backgrounds, they reveal similar processes operating at both the organisational and individual levels.

There would appear to be at least two vital components underpinning both high reliability organisations and individual excellence: a mindset that expects unpleasant surprises and the flexibility to deploy different modes of adaptation in different circumstances. In short, there is a mental element and an action element. Of these, the former is at least as important as the latter. Effective contingency planning at both the organisational and the personal levels depends on the ability to anticipate a wide variety of crises. Both components are resource-limited. Any person or organisation can only foresee and prepare for a finite number of possible circumstances and crisis scenarios. Crises consume available coping resources very rapidly. Only those people or organisations that have invested a considerable amount of preparatory effort in the pre-crisis period will be able to deploy compensatory responses in a sufficiently timely and appropriate manner so as to maintain the necessary resilience.

These three concepts cognitive readiness, pre-prepared responses, and the restricted nature of coping resources proved to be extremely valuable in interpreting the data obtained from the surgical study described below.

The Surgical Compensation Study

Background

Over the past few years, we have been investigating the compensations carried out by UK paediatric cardio-thoracic surgical teams during the course of the neonatal arterial switch procedure (Carthey, de Leval, Reason, Leggatt, & Wright, 2000). We were fortunate in having a skilled Human Factors observer present at 165 of these procedures. In other words, it was an event-independent study. Twenty-one consultant surgeons in 16 institutions throughout the country performed these neonatal switch operations.

The Arterial Switch Operation

The arterial switch operation (ASO) involves correcting cardiovascular congenital defects in very young babies by transposing the great arteries the pulmonary artery and the aorta so as to permit the full circulation of oxygenated blood. Without such an intervention, the child would die. The children upon whom the ASO is performed are bom with the great vessels of the heart connected to the wrong ventricles: the aorta is connected to the right ventricle and the pulmonary artery to the left ventricle. The operation may last for 5-6 hours and is highly demanding both technically and in human terms.

The most challenging part of the procedure involves relocating the coronary arteries, each comprising very thin friable tissue. The arterial switch procedure takes the surgical team and particularly the consultant surgeon close to the edges of the human performance envelope on a variety of parameters: psychomotor skills, naturalistic decision making, and in its claims upon knowledge, experience, leadership, management, and communication skills. Errors of one kind or another are almost inevitable under such conditions. What matters are not the errors per se but whether or not they are detected and recovered. In the surgical context, as we shall see, bad outcomes happen when major adverse events, usually the result of errors, go uncompensated; happy outcomes by far the majority are due in large part to effective compensation by the surgical team.

Events and their Compensation

On average, there were seven adverse events per procedure. One of these was life- threatening (a major event); the remaining six were relatively minor events that disrupted the surgical flow but did not immediately jeopardise the safety of the patient. Nearly all of these events arose as the result of errors on the part of the surgical team.

Over half the major events were successfully compensated. When this happened, there was no increase in the risk of death in that particular procedure. However, only 20 percent of the minor events were compensated. Surgical teams varied in their compensatory success. Good compensators had good outcomes. Compensation for minor events was far less important than their total number within a given operation. The larger the number of minor events, the less likely were the team to cope effectively with a major event. Minor events appeared to exert an additive effect by cumulatively eroding the limited compensatory resources of the surgical team.

The message from this study was clear. All surgeons make errors, but the best of them have the ability to compensate for any adverse effects. This ability depends on the skill and experience of the surgeon, as well as the extent to which they have mentally rehearsed the detection and recovery of their errors.

The Variability Paradox

The reduction or even elimination of human error has now become one of the primary objectives of system managers. Errors and violations are viewed, reasonably enough, as deviations from some desired or appropriate behaviour. Having mainly an engineering background, such managers attribute human unreliability to unwanted variability. And, as with technical unreliability, they see the solution as one of ensuring greater consistency of human action. They do this through procedures and by buying more automation. What they often fail to appreciate, however, is that human variability in the form of moment-to-moment adaptations and adjustments to changing events is also what preserves system safety in an uncertain and dynamic world. And therein lies the paradox. By striving to constrain human variability, they are also undermining one the system’s most important safeguards.

The problem has been encapsulated by Weick’s (1987) insightful observation that ‘reliability is a dynamic non-event’. It is dynamic because processes remain under control due to compensations by human components. It is a non-event because safe outcomes claim little or no attention. The paradox is rooted in the fact that accidents are salient, while non-events, by definiti...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Foreword
• Preface
• Editorial Team
• Review Team
• List of Tables
• List of Figures
• Selected Contributors’ Biographies
• Part 1: System Safety and Accident Prevention
• Part 2: Contrasting Human Factors Applications in Aviation, Healthcare and Nuclear Power
• Part 3: Training, Licensing and Regulations
• Part 4: Automation and Human Computer Interaction
• Part 5: Human Factors Applications Within the Ats Environment
• Part 6: Other Human Factors Issues