Aviation safety as we practice it involves examining accidents for causal factors, “errors and omissions,” and deriving theories about what the pilots are doing wrong. Our primary mission in generating safety is to identify and mitigate threats and trap errors. And while there is value in this approach, it gets depressing since pilots end up as the root cause for everything that is not mechanical; roughly 80% of all wrecks. Additionally, important lessons on what “quietly goes right” are usually missed and engineers increasingly work to design planes without pilots since we are perceived as the “weak link.” In some respects, this approach to safety 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. And the statistics look a lot better with this wider analysis.
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. 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 help us optimize and improve pilot performance. This is often missed in organizations due to an overfocus on perfection and predictability. An important take-away from Dr. Holbrook’s work is is caution, “Many paths take you away from what you want to avoid, but not every path away from danger is a path toward safety.”
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