Beyond “Never Do This” In Safety!

Aviation safety as we currently practice it involves examining accidents for causal factors, “errors and omissions,” then deriving theories about what the pilots are doing wrong to improve our future flying. The primary method of generating safety is by identifying threats and trapping errors.

While there is value in this historic approach, learning “what not to do” is only one side of the safety coin. And playing “whack a mole” with errors might never exhaust the list of creative screw-ups. The statistics compiled in this fashion are depressing since, by definition, the pilot is the root cause of every accident that is not mechanical whack-a-mole-cartoon(roughly 80% of all wrecks). Engineers increasingly work to design planes without pilots since we are statistically the “weak link” in aviation safety. Meanwhile, important lessons on what “quietly goes right” are usually missed with this solely negative focus.  In some respects, this methodology is “like trying to learn about marriage by only studying divorce.”

A new approach to aviation safety is being pioneered at the NASA Engineering and Safety Center involving a more comprehensive examination of all aviation operations, not just the accidents. Led by Dr. Jon Holbrook, and termed “productive safety,” he examines all the ways pilots actively contribute to safety during complex and challenging operations. “For every well-scrutinized accident, there are literally millions of flights in which things go right, and those flights receive very little attention,” said Holbrook. The statistics look a lot better with this wider analysis since positive contributions of successful flights are added into the mix.

In Focusing [Just] On What Pilots Do Wrong, We May Be Missing Valuable Lessons From What They Quietly Do Right -FORBES

This “productive safety”  orientation toward “what we are doing right” has become a trend in industrial safety also. It is philosophically more consistent with the recent FAA switch to a collaborative compliance philosophy (and away from just strict enforcement). Even the last century’s “Six Sigma” obsession with eliminating error ( Six Sigma is 99.99966% error-free) has fallen from favor in modern industry. A more balanced approach to safety provides a bigger toolbox to assure safe operations in all human endeavors (and in industry spawns more innovation).

Veteran human factors psychologist Dr. Gary Klein has a performance paradigm he calls the “macro cognitive perspective” that nicely blends these two focuses of protective and productive safety when studying complex systems. Certainly in safety work, we have to study accidents carefully to identify and avoid errors and manage risks. But there is also an “up arrow” in high-stakes human performance that helps us optimize and improve pilot performance (glass half full viewpoint). This is often missed in organizations due to an overfocus on just errors, perfection, and predictability. An overriding caution from Dr. Holbrook’s work is the continuing evolution of safety in complex operations, “Many paths take you away from what you want to avoid, but not every path away from danger is a path toward safety.”

Here are some slides from this study and more information in an article in Forbes.  Fly safely out there…and often!


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Author: David St. George

SAFE Director, Master CFI (12X), FAA DPE, ATP (ME/SE) Currently jet charter captain.

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