Paul Phelan/CAIRNS
Has cockpit resource management (CRM) delivered the safety outcomes projected when the concept was launched in the early 1980s? Not universally, admit specialists such as Robert Helmreich, Ashleigh Merit and John Wilhelm of the seasoned human factors group at the University of Texas.
Airline and pilot attitudes to CRM have ranged between scornful rejection, passive adoption and unswerving acceptance, but the aviation psychology community asserts that much of the potential of human factors activity has yet to be developed and exploited fully.
The Texas group readily admits that CRM does not reach everyone, and that failures are found in every airline; that there is often "slippage" of the acceptance of basic concepts over time (but for correctable reasons); and that CRM does not "travel well" between airlines or between national cultures.
MANAGING ERRORS
The group insists, however, that the growing international dialogue in human factors is measurably improving air safety, as well as airline economics, and that new initiatives can now reach far beyond early CRM philosophies into company-wide safety-system enhancement through "error management". Leading human factors exponent Professor James Reason has asserted that "-error-prone people do, of course, exist, but they seldom remain at the hazardous sharp end for very long. Quite often, they get promoted to management."
Reason's observation, cited by Helmreich at Australia's biennial Aviation Psychology Association Symposium, echoes the new outlook of other human factors experts. The symposium was told that progressively safety-aware carriers are now also focusing on the expansion of aircrew-related human factors practices into error management in other airline employee roles and, more especially, into management and board structures.
The Australian symposium has became a catalyst for the regional exchange of human factors philosophies and initiatives, offering a commercially neutral forum in which uninhibited air safety dialogue provides vital input for less experienced carriers from neighbouring states, some of which (unlike the bare-it-all Australasian airlines) are traditionally reserved about external discussion of safety issues, and some of whom do not always publish detailed accident analyses.
Now emerging from about 40 years of total regulatory protection and resulting over regulation, Australian and New Zealand carriers have had to learn quickly in a newly competitive environment. With an unusual degree of frankness, these airlines are sharing their learning experiences with any regulator or airline which might benefit. For others in the region, this unreserved commitment of carriers and regulators to detailed public analysis is an almost indispensable safety aid and explains the consistently high level of attendance at the forum.
As yet, the interchange of safety information has been almost totally unidirectional, but Australasian operators and regulators and Australia's Bureau of Air Safety Investigation (BASI) hope that their region's reputation for unreserved safety-positive analysis will generate enough confidence in other regional participants to encourage them to be equally involved.
The benefits of that candour are illustrated by recent events, when Ansett general manager of operations Capt Trevor Jensen, a vocal proponent of radical airline safety systems overhaul, launched his review of the company's safety structure (Flight International, 8-14 July). BASI director Dr Rob Lee asserts that there is now growing impetus for other airlines to review their safety systems as Ansett is doing. "There's a realisation, driven by commercial considerations - including the concerns of insurers, who want to look at how the company is set up in terms of safety systems. If you don't have them in place, you can be at a serious commercial disadvantage. The realisation is growing, but it's still far from universal," he says.
Before it becomes universal, corporations aspiring to a sound safely culture will need to look within their organisational conscience and strongly confirm their commitment, warns Patrick Hudson of Leiden University's Centre for Safety Research, describing the evolution of a typical airline safety culture. "At the first stage of development, we can see the values beginning to be acquired, but the beliefs, methods and working practices are primitive. Top management still believes accidents to be caused by stupidity, inattention, and even wilfulness on the part of its employees. Many messages may flow from on high, but the majority still reflect the organisation's primary aims-often with 'and be safe' tacked on at the end," he explains.
The next stage, says Hudson, is one that cannot be circumvented, and demands the recognition that safety needs to be taken seriously at all corporate levels. The term "calculative" is used to stress that safety is calculated; quantitative risk assessment techniques are used to justify safety, and to measure the effectiveness of proposed measures. "Such techniques are typical problem-solving methods. Often simple calculations suggest that failing to be safe - or at least having incidents - costs money," he says.
Hudson also warns that organisations which are seen from outside as being "uncaring" about safety may have image problems that render a negative impact on the bottom line. "Despite this stance, and despite what can become an impressive safety record, safety remains an add-on, certainly when seen from outside," he says.
The calculative phase lays the foundation, nevertheless, for generating beliefs within the organisation that safety is a worthwhile goal in its own right. "By constructing deliberate procedures, an organisation can force itself into taking safety seriously, or can be forced by a regulatory body, but the values are not yet fully internalised, the methods are still new and individual beliefs generally lag behind corporate intentions," Hudson says.
"Only when the value system associated with safety and safe working has been fully internalised and has became consistent with the beliefs almost to the point of invisibility, and the entire suite of approaches the organisation uses are safety-based, are the preconditions met for the establishment of a true safety culture," Hudson believes.
"We can see how crucial the notion of belief is. The overt knowledge about safety, taken together with a set of values, may still not be enough when difficulties arise, although, in easy times, behaviour may be exemplary. In the last resort, what drives a person and, I would argue, an organisation, is less their knowledge than their beliefs," Hudson says. "When knowledge clashes with belief, the more deep-seated is likely to come out on top as the driver of behaviour. Beliefs, even as articles of unjustified faith, are more deep-seated than any rationally acquired knowledge. The latter may be easily disproved or set aside: belief is much harder both to induce and, then, to shift."
CORPORATE CREDIBILITY
It is in the shaping of beliefs within the workforce and management, as a foundation for safety cultures, that a corporation must look to its own credibility, Hudson warns. "Poor expectations are, typically, due to the fact that needed improvements have not been implemented nor necessary conditions created. When procedures are known to require a certain amount of time, and the time made available is never enough, the values and intentions may be exemplary, but it is the expectation that drives the final behaviour," he says.
Professor Ron Westrum, of Eastern Michigan University, says that "organisational learning" must be of a high order before a corporation will progress to the final stage - identified in his studies on high reliability organisations and labelled "generative". This stage involves the much more positive approach to safety that progressive carriers now display.
Westrum cites the crash of a Boeing B-52 near Guam in 1993 as an example of the need for organisations' accumulated experience to be stored and analysed. The pilot had a lengthy record of violations, but was protected by successive colleagues, each unaware of previous violations. Westrum details organisational shortcomings identified after the event, which may lurk within any airline and will obstruct the development of a positive approach to safety:
1. failure to deal honestly with each event as it occurred;
2. failure to collate these events, so that they could be seen as a pattern;
3. failure to monitor base morale, a key management responsibility;
4. failure of self-awareness.
"The facts were present. But they were not developed, they were not assembled and they did not cause action," he says.
These obstacles cleared, says Hudson, the stage is set for a positive safety culture which permeates the entire organisation. "Whereas the calculative stage represents a reactive approach, using past experience to determine future behaviour, the generative approach may be characterised by a much more internalised model of 'good practice' as its driver.
"This model becomes internalised as a set of beliefs about why and how the organisation operates and about what is the best way to do things," he says. "Assumptions about the 'need' to be safe are unquestioned; everything else, in contrast, is open for discussion and improvement. A characteristic of this stage is the lack of complacency, even in the face of a dearth of accidents. This has been labelled 'chronic unease', which sums up the pessimistic stance that the fact that everything has gone well is an indication that what is about to happen will be a new experience. Chronic unease represents a positive aspect of expectation that something can easily go wrong. Fortunately, chronic unease is balanced by optimistic presumption that what does happen can be faced and coped with. It does not imply shrinking from challenge, nor pessimism elsewhere," Hudson says.
A crucial difference between this and previous stages is that the human factor is considered to include both the individual and the organisation, asserts Hudson. "The model of human behaviour has shifted from one in which workers have to be driven, and are not to be trusted, to a more mature understanding of what makes people tick. It is only at this point that it becomes possible to understand that the establishment of a safety culture is still not enough, on its own, to counter all human error because such errors may be outside the control of the immediate perpetrator. The full development of a safety culture requires the transition from technique to practice," he concludes.
Source: Flight International
