Features Procedures Safety & Training
Reading Between the Lines

For a nice change of pace in this issue, Helicopters Safety and Quality columnist Walter Heneghan selected three books from his personal collection that have influenced, in one way or another, his passions towards aviation.

Checklists are a pilot's best friend and seem able to defend anyone against failure. (Photo courtesy of High Terrain Helicopters)

“I didn’t realize until after I had completed the reviews that each book is related to one of the others, from the perspective of safety in aviation,” said Heneghan.

The first book, Ernest K. Gann’s Fate is the Hunter, sets a historical perspective of the early days of aviation and feeds nicely into the second work, Professor James Reason’s valedictory work recalling his voyage into the world of human error, A Life in Error.

Heneghan then leapfrogs into the field of medicine by introducing readers to Atul Gawande’s paradigm-shifting essay, The Checklist Manifesto, where he writes of using aviation solutions within medicine to alleviate human error.

This triptych of writings provides an interesting variety of retrospective, theory and changing hypotheses within and outside of aviation. All of the reviewed books are available from Amazon.

Fate is the Hunter: A Pilot’s Memoir
“ . . . There, then, was the enormous mass of Greenland, and I could not look away from it. It held me as it took on colouration and I finally distinguished the warts as the peaks of great mountains. And all about them, choking their gigantic necks, lay the awesome icecap. I had never in all of my flying seen anything to compare with this fantastic exhibition. . . . In all of the times I later came upon the continent of Greenland, the crew members invariably expressed the same wondrous exhilaration.”

Some 35+ years ago when my aviation career was nascent, I fed my budding interest in the field through my monthly date with Flying Magazine between study sessions with my Pultz guide for private pilots.

But my passion for flying was truly ignited when one afternoon I searched my father’s book collection and lifted Ernest K. Gann’s Fate is the Hunter from the den bookcase. I recently revisited this classic of aviation literature and again found it igniting a passion, albeit now from a perspective of experience rather than anticipation.

Gann is no stranger to fans of aviation story telling and great prose. Born in 1910 in Lincoln, Neb., Captain Gann pursued an aviation career at a time when commercial aviation was in its infancy. His memoir traces a path from his exploits as a young barnstormer through his days with American Airlines and includes anecdotes from his experiences during the Second World War flying to Labrador and Greenland and his work in the industry afterwards.

Published in 1961 by Simon and Schuster, the book is part aviation history, part flying manual and, most importantly, a delightful read. As demonstrated by the passage describing his initial voyage to Greenland, Gann demonstrates a proficiency in writing that grips and satisfies even the most discerning reader.

The book begins with a passage that has remained with me all my life. Gann writes of a nighttime flight from Buffalo to New York City, two pilots and 11 passengers winging their way in the dead of night towards La Guardia airport.

The aircraft is purring along without issues, and the banter in the cockpit is typical of that between two pilots. Gann writes of the typical insecurities of less experienced copilots and reflects on the various and sundry duties required while away, from the time of takeoff to landing. He notes, however, that the aircraft has been cleared to maintain an altitude of 5,000 ft. MSL but they are flying along, steady as can be, but 50 feet high.

Gann has no explanation why at that particular time, the discrepancy “speaks” to him. In a fit of self-chastisement, he decides to adjust the throttles, re-trim the airplane and reduce altitude by the 50 errant feet. He prides himself in being a professional pilot, no other explanation. Yet, some 30 seconds later, their windscreen is filled with the apparition of another aircraft, in an opposing direction, perilously close to their flight, estimated to be a mere 50 feet above them.

The retelling of this event set the stage and tone for the remainder of the book: gripping, folksie, prescient, relevant. Several more anecdotes including one involving an oil leak over the jungle of South America that happened to be witnessed by Gann and thus allowing the crew to save the airplane, drive home the premise of his book: sometimes things happen for no apparent reason, sometimes fate, as a higher order, intervenes and leads a flight crew to do or say something that results in saving lives. Fate, the hunter; Pilots and their passengers, at times the hunted.

This book remains a great read today and one that should be a mainstay in all pilots’ libraries.  There is great wisdom in Gann’s retelling of his experiences, including this passage that may have been written 50 years ago, but is no less relevant today:  . . . “a line pilot is wary all of the time, which is an entirely different matter. To be continuously aware you must know what to be wary of, and this sustained attitude can come only from experience. Learning the nature and potentialities of the countless hazards is like walking near quicksand.”

 A Life in Error: From Little Slips to Big Disasters
“This book is written for all those who have an interest in human factors and their interactions with the workings of technological systems whose occasional breakdowns can cause serious damage to people, assets and the environment.”

Helicopters safety and quality columnist, Walter Heneghan knows the value of a good book. (Photo supplied by Walter Heneghan)

No student of safety, risk management, human error or accident investigation is a stranger to the writings, teachings and behavioral models of James Reason. His name invokes a knowing nod, as many of us know him as the author, father and advocate of the Swiss Cheese Model of accident causation.

(As a shout out in preparing this review, a Google search shows nearly a million hits!) A Life in Error takes us back to the beginning and provides some insight into the man and the mind behind this paradigm shifting model and his lifetime endeavours.

This book is an easy read. Professor Reason’s literary manner belies his academic background yet he stays on point and provides a bona fide reference text for his lifetime work. It is not meant to be an all-encompassing anthology from his career, but more of a retrospective roadmap.

When given the opportunity to expound on a particular thread, Reason chooses to reference previous publications or writings so that the flow of his review remains uninterrupted.

He also provides a relevant bibliography along the way, for those of you who are inspired to explore past his précis. This structure keeps the reader engaged while simultaneously presenting an intellectual stimulus.

His recollection of adding cat food to his teapot speaks of an error that shifted his focus of academic study towards the field of human error; a serendipitous error that arguably changed the way we all look at how accidents occur!

Professor Reason quickly goes through the notion of plans, actions and consequences including his definition of error: “… [when] a planned sequence of mental or physical activities fails to achieve its desired goal without the intervention of some chance agency.”

He proceeds to write of performance levels and error types: skill based, rule based and knowledge based mistakes and how they interact with each other. It’s simple yet provocative.

There is an interesting section wherein Professor Reason writes about slips and specifically the role Sigmund Freud played in addressing the issue of “slips” in modern society.

This is another piece of the error puzzle that informed Reason’s theories over the years in that “…Slips, we now believe, provide important glimpses into the minutiae of skilled or habitual performance.” Yet another teaser from his psychology background and a fundamental piece of his accident causation theories.

Reason’s discussion of violations provides valuable perspective on why people willfully disregard directives and procedures.

Routine, optimizing, necessary or exceptional violations are briefly explained in the context of some very well-known disasters, Chernobyl and the Piper Alpha explosions among them and serves as a nice segue into a discussion of organizational failures. This section of the book is representative of his more recent work in aviation accident causation and references the safety cultures that may underpin organizations.

Professor Reason then diverges into a discussion on medical errors; his most recent life-passion. These final chapters briefly address the significant challenges faced by medical communities worldwide in addressing error, particularly within the context of patient confidentiality, physician accountability, reporting processes and broad disclosure. Again, the chapters tease the reader into wanting more, but he delivers no answers, just the motivation to research the matters more thoroughly.

To follow Professor Reason’s retrospective is to have been given a chance to turn back time and follow him from his early days of psychology through the looking glass of accident causation into the medical profession. This valedictory work (his words) blesses us all with an insight of one of the most influential minds in his field. His last words: “Be safe.” Indeed.

The Checklist Manifesto
Checklists. As aviators they are as common to us as oatmeal for breakfast. Yet in the medical community they have been eschewed as impediments to the delivery of patient care, or worse, outright challenges to the absolute authority of doctors. Atul Gawande, a physician himself, challenges these and other attitudes in his groundbreaking work, the New York Times best seller, The Checklist Manifesto.

The Chernobyl disaster in Russia is the perfect example of an organizational failure. (Photo courtesy of Denis Avetisyan)

Right off the bat, one is gripped by two tales from the vast repository of miracle saves in emergency medicine, each with its own moral, and each with its own piece of luck. It sets the background of his book: that notwithstanding the incredible progress within medicine for greater diagnostic tools, and better learning, medical error is still frighteningly common, even in those circumstances that result in a “positive patient outcome.”

He postulates that not just medicine but other complex systems have become burdened by knowledge and that there is a “ . . .  strategy for overcoming failure . . . that builds on experience and takes advantage of the knowledge people have . . . [and] makes up for our inevitable human inadequacies.” The checklist.

This book explores the perspective of one who wanted to repurpose a tool that has been used in aviation since the dawn of piloting. I have written of Professor James Reason’s voyage into the realm of medical error and we can now follow a medical insider into how he believes medicine can benefit from aviation’s own
blood lessons.

Gawande’s prose makes for easy reading and his frequent use of personal and real-life examples moves the work along nicely. Particularly poignant is the author’s use of studies and statistics to support his premise: Checklists can save lives, in his words: “ . . . checklists seem able to defend anyone, even the more experienced, against failure in many more tasks than we realized, [providing] a kind of cognitive net.”

He then takes an odd turn by entering into a deep study of construction practice – of how large office buildings are built, all to hammer home the point that the most complex tasks or problems are solved by teams, not individuals, and that mature communication practice is what drives success.

Considering the thousands of structures built in North America every year, an Ohio State University study found that the annual avoidable failure rate is less than 0.00002 per cent – suggesting that checklists, in very complex systems, do indeed work.

Gawande’s journey leaves few stones unturned, from Walmart to FEMA, local restaurants to the World Health Organization before returning to aviation and entering into a discourse about exactly how aircraft manufacturers and their test pilots develop the checklists in use on-board commercial airliners today.

He writes of how the same manufacturers research and investigate failure and have well-developed communication channels in place to disseminate process improvements to the operators of their aircraft. Checklist amendments involving critical systems have been promulgated in less than 30 days resulting in better risk management within their worldwide fleets and, in some cases, demonstrably saving lives. It’s all about communication and checklists, working hand in hand.

Gawande’s argument is convincing. From safe surgery checklists, to having operating room team members introducing themselves prior to starting surgery, there are many ideas put forward in this book that just seem to make sense, and are supported by research and experience. But he remains uncertain if the profession is ready to embrace the somewhat pedestrian, yet elegant, Checklist Manifesto.