Air safety: A new approach

I feel defeated. Just after publishing a book about air safety, a new technique appears reducing to crap everything. Enjoy it:

 http://aviation-safety.net/news/newsitem.php?id=1888

Air safety and Organizational Learning: Improving Air Safety through Organizational Learning

https://www.ashgate.com/shopping/title.asp?isbn=0%207546%204912%201

This is the information that Ashgate shows in the 2007 brochure about a book signed by one of the partners of Quasar Aviation.

  The author -who writes this comment- does not proceed professionaly from the aviation field. However, flying is enjoyable and, at the moment of writing this, 22 years passed flying anything below 1.500 kgs. with or without engine except helicopters .

Due to professional reasons, he was required to obtain a Ph.D. As usual, the author tried an easy way: Having good contacts available in the aviation field, it should be easy getting information.

Nevertheless, the learning model used to improve safety level seemed to be good. If so, a good option should be looking for learning elements that could be transferred to the management field.

That was the first idea and this was the first surprise:

http://www.boeing.com/news/techissues/pdf/statsum.pdf

As can be seen, the improvement line becomes almost flat around the end of the 70s.  However, it was an hypothesis to test: The system could be so good to be hard to improve since any marginal improvement could be very costly (something that Quality people know very well).

The hypothesis had a good looking but it was still another surprise:

http://www.fas.org/irp/threat/212fin~1.html

The White House Commision for Air Safety and Security stated that it was required an improvement factor of ¡¡5!! because, otherwise, keeping the present safety rates and due to traffic increase, we could expect a major accident weekly in 2015.

In other words, the system had to improve and it seemed to be unable to do it even in the face of a very hard pressure.

That was the moment when the idea of getting a Ph.D. using a shortcut -a legitimate one- dissapeared and it was required to go in depth to know where the learning problems were and how to avoid them. That was the thesis.

Later, and after presenting some papers in the aviation field, this was commented with Ashgate and it was another surprise: Ashgate was interested in the aviation part, not in the business management part. Actually, the echo of these ideas in the business management community had not been very relevant and, by the other side, they were well-accepted in the aviation field.

Ashgate wanted the book more aviation-centered suppresing the reference to business management. The result is this book.

There is an issue pending. Probably some ideas that could be good in the business management field are going to be lost. Ashgate had a very clear idea about which part of the original work was interesting for them and nobody could say anything negative because of that.

The lamentable issue is in a very simple fact: The aviation field has suffered more pressure to learn than the business management field. That made aviation to advance faster and -this is the relevant part- problems arising in air safety are going to appear in the short-to-medium term in business management since the learning model is alike.
Knowing what happens in air safety is a good way to forecast -and prevent- problems in business management but, until the moment, this is an approach that has been undervaluated from the business management side.

For obvious reasons, the author cannot tell nobody if the book is or not well-written. For non-native speakers, that is always hard and the writer is not the right person to evaluate himself.

I hope this comment can clarify the contents of the book to give the reader an idea about if it is worth the money or not.

Air crash in Brazil

This is a moment to wait. Everybody tries to anticipate conclusions and many of them are simply absurd.

As an example, a newspaper from Argentina said that this accident was similar to the one of LAPA in Buenos Aires. Both planes left the runway, broke the fence and were destroyed…So what? The journalist wanted to be original and, instead, has shown himself as stupid.

Nobody knows what happened but every time that a big accident occurs we see that not  everythig is under control however that is the idea that the industry tries to sell to the passengers.

If passengers know that when they come on board of a plane, they are assuming some risks as they know that when they enter a car, they will pay more attention to safety issues.

What happened? Many things could happen and, as usual, the accident probably will be produced by an exceptional convergence of several different and unrelated things. A wet runway? Bad information from the control? Fatigued crew? Technological complexity of the plane? Tunnel vision? A bad decision once the plane was landed?

That is something to be clarified by the investigation but not today or tomorrow. It can be one or more of the proposed causes or, perhaps, any other different. An airport that should be closed? A mobile phone of a passenger? Who knows?

When a relative dies in a traffic accident, we discover that deaths are not only statistical information about weekends. Corpses are real and aviation has shown that is risky through the lives of more than 200 people.

We have to know that. The “show” of life-jackets and emergency exits is something that the average passenger forgets or, directly, does not pay attention. It is true that the probability of an emergency evacuation is very low but, if we have to do it in am important accident, we only have 90 seconds. After that, if we are not out of the plane, we’ll never leave it. That is the difference between life and death.

What about masks? If we need them and we wait for more than 15 seconds, we cannot do it anymore because we lose the conscience. That is why we have to use our mask before trying to help any other, even our little baby.

What about mobile phones? The waves can affect to flight information systems and, in some models, to flight control systems. The person that is waiting for you at the airport can wait some more minutes before receiving your phone call.

The auxiliary crew are not there to serve coffee.  Actually, there is a rule: One flight attendant for every 40 passengers. Do you think that the rule is made to assure that your coffee does not arrive to you cold? Certainly not. These are key people in the eventuality of an emergency evacuation.

Of course, this is not going to be the last aviation accident. However, aviation is safe but safety is not intrinsic. Safety is created by many people working to get that and you, as a passenger, has something to do:

First, put safety among your decision criteria when you buy your next flight ticket.

Second, be aware of these little “tips” above and act accordingly. Accidents not only happen to others. We can do things to avoid them or to survive them.

The myths in Internet

If you have arrived to this blog, probably this video is very well-known for you:

 http://vids.myspace.com/index.cfm?fuseaction=vids.individual&videoid=1404617136

However, the most important part is not the movie but the comments made by the person who uploaded it.

Please, compare the comment with this:

Air Show A-320

Both speak about the same accident. Of course, this is not a kind of crash-test where the manufacturer -supposedly- crashes an unmanned brand-new plane.

This was a real accident with real victims. However, I have seen the myth of “unmanned flight” in more places in Internet. Perhaps this is an intrinsic problem. Through Internet, we can get a lot of information but, at the same time, we have to be able to filter the crap.

The new frontier of air safety

For many years, air safety has been increasing. This link can be one of the best proofs about that:

http://www.boeing.com/news/techissues/pdf/statsum.pdf

However, it can be observed that the rate of improvement has decreased dramatically since about 30 years. The worst part: It happens in the face of the biggest technological improvement known in recent times.

How can we reverse the tendence. Are we going to be able to recover the former improvement rate?

A possible answer should be “Not through the present use of technology”.

It is true that technology has improved but this improvement is not for free but at the cost of other resources. Perrow handled the concept of “tightly-coupled organization” to speak about the progressive constrictions of an environment supposedly designed to deal with ANYTHING that could appear.

The facts show that events have been by far more creative than planners or technology designers. We have improved technology; we have better resources but, at the same time, we have shortened the value of people.

This is not a war between technology and people since both are required. The fact, however, is that the development of one of these resources cannot be made at the expense of the other.

We need to design and use technology in ways able to leverage people instead of focusing in avoiding human error. Certainly, avoiding human errors is important but there is something that we cannot forget: People are not only a source of errors; they are too the only possibility to manage unforeseen situations.

Technology designers decided to include in their designs all the situations that they could imagine to avoid unforeseen situations to appear. Unfortunately, doing that, they built extremely complex systems that could produce, by themselves, new unforeseen situations.

That is why this is not the right way to  increase air safety. The right way implies ability to manage unforeseen situations and that means highly-trained people managing a known technology. Shortcuts do not work here.

From “Air Safety Improvement throught Organizational Learning”

Ed. Ashgate.

José Sánchez-Alarcos

American Airlines 191 -When bad rules kill-

http://www.youtube.com/watch?v=bLuT6ECavfk&mode=related&search=

Rules have a very clear role concerning air safety. They save time and effort at solving problems already solved.

However, there is a situation where rules do not work. It is the situation where the problem has been misidentified and the rule, instead of fixing a situation, contributes decisively make it worse.

http://en.wikipedia.org/wiki/American_Airlines_Flight_191All the information available to pilots told them that they had a loss of power and they applied the right procedure to that situation. Actually, they had lost an engine; this and a new design in the DC-10 model drove to an air disaster.

Limitations to Organizational Learning

Limitations to Organizational Learning

This paper has been presented in one of the biggest meetings in Europe (Euroma 2003) in the track devoted to Knowledge Management.

It deals with learning models applied to Air Safety.

Air Safety as a model of unexpected systemic evolution

Air Safety as a model of unexpected systemic evolution

Maturana and Varela coined a term (operational closure) that was later used by Niklas Luhmann.

This paper, presented in SCI 2002, shows why some changes related to air safety have decreased the real ability of the whole system to improve.

Of course, the system keeps improving and air safety is increasing. However, this is done at a pace quite far from required.

Organizational Learning in Complex Environments: Lessons coming from Air Safety

organizational-learning-in-complex-environments.pdf

This is a paper presented in a meeting about Organizational Semiotics.

The idea of semiotics can sound strange for people coming from the aviation field. However, it is there where the next frontier to increase air safety is.

At the moment of writing this post, a book is going to be published about this issue. The name is “Air safety improvement through Organizational Learning”. Basically, it deals with the same issues that this paper but, however, without the limitations of space of a paper.

Tenerife disaster (Los Rodeos, 1977)

http://en.wikipedia.org/wiki/Tenerife_disaster

This is still the worst accident in the history of commercial aviation.

Some things are very surprising about this accident:

First, the immense amount of bad luck and coincidences that happened to allow this accident to happen.

Second, in a time where the traceability was not especially developed the investigation team made an excellent work regarding reconstruction of the facts.

Third: Despite the second factor, the recommendations in the final reports seem to be “weak”. Many people could miss a reference about organizational factors like the role of “management pilots”.