Safety & Training
Practise Does Make Perfect
April 28, 2014 By Walter Heneghan
Spring is a special time of year in our industry: contracts are being renewed, pilots and AMEs are hired, and training is completed.
Spring is a special time of year in our industry: contracts are being renewed, pilots and AMEs are hired, and training is completed. We are the proverbial bears coming out of hibernation, readying ourselves for a frantic six months of revenue activity to keep our companies alive and prosperous for another year.
It is also marked by what I believe is the premiere industry safety event around – the CHC Safety & Quality Summit. This year marked its 10th iteration and featured such renowned speakers as Tony Kern, Scott Shappell, Sidney Dekker and this year’s keynote dinner guest, Commander Chris Hadfield.
While the theme of this year’s event was, “Safety & Quality in the Real World: Turning Theory Into Practice,” two of the speakers, Dr. Dekker and Commander Hadfield, addressed failure from their unique perspectives. Dr. Dekker has written often on the notion of “drift into failure.” In his technical report entitled, “Why we need new accident models,” Dr. Dekker notes: The greatest residual risk in today’s safe aerospace systems is drift into failure. Drift into failure is a slow, incremental movement of systems operations towards the edge of their safety envelope. Pressures of scarcity and competition that subtly influence the many decisions and trade-offs made daily by operators and management hierarchies drive this movement.
Drift into failure is difficult to recognize because it is about normal people doing normal work in what appear to be normal organizations. This drift is not obvious nor is its associated breakdowns, failures or errors. Perhaps one of the more well known “drift into failure” accidents involved an Alaska Airlines MD80 crash into the Pacific Ocean in 2000 after a jackscrew failure in its trim system in the tail of the aircraft. In synopsis, the inspection and lubrication cycle on the jackscrew when the aircraft type first entered service was 300 hours; at the time of the accident, it exceeded 2,500 hours. The complete sequence of events is a sobering tale of how normal decisions in the context of other, more complex normal activities, can unwittingly set up a system for failure. Other drift into failure events are both the Challenger and Columbia Space Shuttle disasters and even the Deepwater Horizon blowout in the Gulf of Mexico.
Commander Hadfield, in his captivating recollection of his time in orbit, spoke extensively about preparing for failure by accepting that while plenty of things will go right, it is only by preparing and practising for failure that we will stack the deck in our favour when engaged in complex operations.
We pilots do this every year during recurrent training, but how many of us remain conscious of the need to prepare for failure every day on the job? Our pre-flight inspections help us in this regard, as do the daily inspection of ops gear, belly hooks, long lines, water buckets, etc. But how many of us start the day with an overview of our activities and of all the things that can go wrong that day? Bad weather – do I have my survival gear? Do I have sound flight following? Drill moves – is my gear serviceable? Is the staging area clear of obstacles? Is my fuel Q.A. complete? These types of questions help us prepare for failure and may very well be controls or barriers to protect us from the drift into failure spoken of by Dr. Dekker.
Both men are very cognizant of a tendency of successful organizations engaged in complex activities to suffer from the normalization of deviance. This ominous phrase sounds like an academic mumbo-jumbo but let’s consider it for a moment. The normalization of deviance is defined as: “The gradual process through which unacceptable practice or standards become acceptable.” As the deviant behavior is repeated without catastrophic results, it becomes the social norm for the organization. So, in keeping with my spring cleaning analogy – if we didn’t inspect our sling gear yesterday and all was fine, then why bother today? Or perhaps we fly just to minimum fuel limits, just below contract, client or company weather limits, or just close enough to that tree to land closer to the spot for those workers to disembark and go on their way. Day after day, we drift from our standards, we accept deviations as norms and we inch closer to failure.
As pilots, we need to heed the tendencies of complex systems to drift in this manner and incorporate Commander Hadfield’s caution that preparing for failure really is the best defence.
Walter Heneghan is the VP of Safety and Quality at Canadian Helicopters. A passionate advocate for aviation safety and sound risk management, the veteran pilot presents his regular column for Helicopters magazine.