How can we prevent organisational accidents?

Reading the commentary, deep and wide, that has flowed from the saga of the certification and introduction to service of the Boeing 737 MAX there’s palpable frustration. A large volume of analysis and evidence is now in the public domain. It has taken a long time and the persistence of many good people to bring out the results of investigation to the fore.  Frustration stems from knowing that the factors involved in the MAX saga are not new or unique. They have been seen far too often in fatal accidents and serious incidents right across the globe.

One common reaction is to place all the blame on the corrupting effect of large amounts of money. The line “follow the money” became common usage as a result of the 1976 movie “All The President’s Men[1]” despite the theory that it came from elsewhere.

“Follow the money” is good advice for investigators whether they be journalists, air accident investigators or police detectives. It’s certainly one of the known motivators for people to circumvent or disregard rules and regulations.

I could go on to talk about corporate liability[2]. There’s often a distinct lack of capability or inclination to hold large corporations, and the individuals running them liable for gross negligence and unethical behaviours. Another problem with this is that this is the button to press after the event. Yes, strong corporate liability laws rigorously applied can have a deterrent effect. However, the calculation made by those people at the source of the problem is often that of slim likelihood of failure or getting caught or, as with banks during the financial crisis, being too big to fail.

Although all the lessons learned from the analysis of organisational accidents is a good route to prevention of future accidents, that just one part of the puzzle.

Another common reaction is to reach for the human factors’ textbooks. There’s absolutely no doubt that human action is at the root of the events discussed. It takes people, and groups of people to choose to do the wrong thing knowing of the risks they take. Indefensible actions done with the awareness of an organisation are more than just process or procedural failure.

I started writing with the assumption that organisational accidents are preventable and must be prevented. This is to say that zero accidents are achievable. Yet, organisational accidents keep happening and prevention keeps failing. All be it, relative to the volume of global activity, a rare occurrence in civil aviation.

Maybe it’s better to accept that the motivations of a minority of people are to act unethically for personal gain and to take unacceptable risks. The larger problem is the failure of a greater number of people to act when they become aware of that behaviour.

In the cockpit pilots are taught to challenge bad decisions. Maybe we need to teach people how to challenge effectively.


[1] The movie takes protagonists Bob Woodward and Carl Bernstein through their quest to figure out the suspicious acts around US President Richrd Nixon.

[2] https://www.cps.gov.uk/legal-guidance/corporate-prosecutions

Bridge the gap

Trying to understand the motivations of people that I don’t agree with is something I try to do. It can be fruitless and frustrating, but it does get away from social media’s ever-present algorithms. It’s not good to only listen to people with whom I wholeheartedly agree. Last night, in a moment of curiosity I switched on the TV and watched GB News. That’s until it got far too boring.

There’s one sure thing. The channel is nothing to do with News. My observation is that GB News is focused on delivering disinformation to a British target public. Not much cheer or many smiles on this channel. There’s a sullen diatribe of announcements covered in red, white, and blue. Its style is that of a pound shop American Fox News, but tone would have been at home in Soviet times.

The themes are entirely predictable. It goes like this; the European Union is an evil empire but European are weak. The enemy is at the gates. Amongst the worst are “Remainers” and the waves of “woke” minded. Forget hardships, Brexit will one day bring a utopia that others will envy.

An evangelical zeal gushes from the screen. Interviewees who say they once voted against Brexit but now see the light. There’s a strong projection of victimisation. It takes an intolerant form. How dare they say I’m wrong. How dare they say I didn’t know what I voted for in 2016. Underlying this is a collective “they” who are believed to be conspiring to overturn the will of the people.

What makes these observations chilling is that I’ve been told by my local Member of Parliament that British Prime Minister Johnson is being attacked by an unfair prejudicial media. Populists have a sharp partition in their minds. On one side is the righteous propagandists and on the other is the mainstream media, who’s a danger to their cherished projects.

Liberal Democracy loves diversity and media pluralism. Let many flowers bloom. However, these current changes in public dialogue are heading in a dangerous direction. More polarisations will lead to more disillusionment. The middle ground must reassert itself. In starting that journey, I wouldn’t start from here, but we must start from here to bridge the gap.

RE

So, Sir Keir Starmer sees “no case” for the UK re-joining the European Union (EU). Disappointing but, in a way, I’m not that surprised that the leader of the UK Labour Party should say such a thing in the North of England. The audience wishes to hear that Starmer is looking ahead, and not behind.

What was interesting in my mind was the emphasis on – no way back. However, the point is moot. It’s true, there is no way back to the way things were prior to 2016.

Going back in time is reserved for science fiction. I’ve been watching re-runs of the 1980s/90s US TV series Quantum Leap[1]. It’s incredibly enjoyable. Time travel within one’s own lifetime is a fascinating theme for fiction but it’s not happening anytime soon in the real world. Starmer is not Dr Sam Beckett on a mission. Starmer doing involuntarily leaps through spacetime is way beyond my imagination.

Saying there’s no case for re-joining isn’t earth shattering. Those two letters “re” are a millstone. There in the words: return, recreate, revive, restore, revitalise, and even remain. Always the subject is about the past. I know we are a country that loves to revel in the past but let’s dump “re[2]” when talking about future possibilities. The last thing we need is to maintain a sense of repetition. There are times to put the past behind us and create a new vision.

If Starmer becomes UK Prime Minister (PM), and that could be sooner than many think, then the timescale for evaluation of the UK’s relationship with the EU may not be too far off.

Starmer claims he wants to “make Brexit work” if he becomes PM. Now, that’s where his utterances get unwise. Above, I’ve warned about lashing public policy to the past. It’s better that Brexit is consigned to a list of historic mistakes. And besides, why say such a thing when the public’s attention is elsewhere?

When people are asked: How well or badly do you think the Government are doing at handling Britain’s exit from the EU? the answer wallows in negatve numbers. It seems strange that Labour seeks the same hopeless position as the Conservatives.

There’s a desperate need for new vision.


[1] https://www.imdb.com/title/tt0096684/

[2] re- Word-forming element meaning “back, back from, back to the original place;” also “again, anew, once more,” also conveying the notion of “undoing” or “backward,” etc., c. 1200, from Old French re- and directly from Latin re- an inseparable prefix meaning “again; back; anew, against.

Regulatory Freedom

Not for the first time a Conservative Minister[1] under pressure was asked to defend Brexit and the answer they gave was: “regulatory freedom.” Sounds good, doesn’t it? But it isn’t often that an audience is given the opportunity to critically assess what it means. So, let’s explore what those two words mean in the context of Brexit. Naturally, it’s highly political given that the word “freedom” is used to imply that a freedom has been acquired that was once was denied.

There are two basic points that come to mind.

  • One: European Member States work together to make new laws and regulations. The UK was highly influential in shaping European policy, laws, and regulation. The UK Parliament once kept a close eye on the progress of the significant developments in Europe, and
  • Two: For all the time of the UK’s membership of the EU, most of our laws and regulations were made by the UK. Since the Member States hadn’t given the EU the competence to act of defence, crime, welfare, direct taxation, national security, and health, for example.

It is sad that Conservative Ministers continue to lie about these facts. Honestly, with 6-years under our belts since the referendum, you would think that a senior British politician would have no need to lie about such matters.

I expect Minister Jacob Rees-Moog[2] is, at this moment documenting the ways in which this myth can be perpetuated. What would be even sadder than sad is if the motivation to change British laws and regulations was just to be different for the sake of difference.

The UK Government has established a Brexit Opportunities Unit[3]. Again, with 6-years under our belts since the referendum, you would imagine that whatever opportunities there are they would be well known by now. Reading the published 4-page report on regulatory-reforms it is thin to say the least.

The face palm[4] I had when reading one line talking about reviewing restrictions on selling in pounds and ounces was a massive one. Did we really go though all that pain for something so trivial? Please don’t answer that question.


[1] https://www.bbc.co.uk/iplayer/episode/m0014b4c/question-time-2022-10022022

[2] https://www.independent.co.uk/news/uk/politics/jacob-reesmogg-what-is-the-brexit-opportunities-unit-b2010570.html

[3] https://www.gov.uk/government/publications/brexit-opportunities-regulatory-reforms

[4] https://en.wikipedia.org/wiki/Facepalm

Aircraft Level View

The latest innovations in aircraft design are, without question, highly integrated systems. We have departed from the days when every aircraft system was a box. An autopilot, a display computer, a power controller may all sit in one cabinet of equipment. Each one interdependent upon the other.

The other day, I saw advertised as an antique a British P8 aircraft compass. Maybe, 80 years old, it was claimed to be still working. This bit of kit was fitted to the Spitfire, Hawker Hurricane and Mosquito. Truly, a discreet equipment. One basic function and independent of all other aircraft systems except cockpit lighting. Afterall, a compass isn’t much use if you cant see it.

One reflection of mine from times past is the real difficulty of getting people to take an aircraft level view. Some might say this is aerospace design history. It certainly was a major struggle in the mid-1990s. It was a message that was not always well received.

Without mentioning any names, I’d roll up at an aircraft manufacture and be confronted with a hanger sized office divided up into cubicles. Sound absorbing partition walls of shoulder hight stretching far into the distance. This is where the Scott Adams[1] got the idea for the Dilbert cartoons.

In one corner of the engineering building would be a venerable grey-haired gentleman who had spent his entire life working on toilet flush motors. At another corner would be a gaggle of whizz kids developing software specifications for the latest computing hardware.

Everything was the same placid light green with only a few signs to give identity to groups of people working together. Segregation and segmentation were a part of the process. Each functional group developed their skills to the highest degree in their chosen specialisation.

My role in all this was to sit in a rectangular meeting room receiving briefings from each technical team. The certification task had been divided up and everyone was doing their part. Certification plans for an autopilot, a display computer or a power controller were all competently presented. Preliminary safety assessments were dutifully described.

After a while it became all to clear to me that everyone was dedicated to their assignment but that communication between different teams was sketchy to say the least. So, questions like, where did you get that number from, when talking about a failure probability number taken from someone else’s analysis wasn’t always convincingly answered. As a result, I got to hammer on about the need to take an aircraft level view to the point of great irritation. It’s not that people didn’t want to hear the message. It was more that the means to look at interdependencies between aircraft systems was fragile and underdeveloped. We changed and progressively the challenge of integration was met.

Today, I sit and wonder if the new entrants in the aerospace world, rapidly putting together advanced new forms of air mobility, have taken on-board the lessons we learned in the 1990s. It’s not as easy to learn the above lessons unless the reason why is abundantly clear.


[1] https://www.scottadamssays.com/

Certification

In the wake of the Boeing 737 MAX troubles the purpose of aircraft certification has come under fire. It was intense fire too, as the subject was taken into the political arena. Both informed, and not so informed public accusations had to be addressed in a comprehensive and systematic manner. The outcome is real change impacting the way organisations and administrations work.

A basic framework is set by international agreement. The standards and recommended practices of ICAO Annex 8 sets a framework within which aircraft certification work is undertaken. Across the globe Administrations/ Agencies/Authorities cooperate to set common minimum standards.

We can talk about process, procedures and standards until the cows come home. These are ever evolving to cope with technical challenges and the experience of operation. What’s more fundamental, and almost never mentioned is what practitioners do day-to-day. Ultimately, despite the subject being highly technical it is people that are at the core of the activity.

Practical necessity mean that an aircraft project has an ambition and a time scale. Although projects are often known to overrun there’s no infinite pot of resources to carry on regardless. Good project management can be the make or break in realising an ambition.

What that means is that there is a constraint on aircraft certification. There is a window of opportunity to undertake the work in a comprehensive and systematic manner.

The true art becomes asking the right question at the right time. Yes, there is an intricate structure within which questions are asked but it is the nature of those questions that makes the diffidence. Ask a bland and easily answered question and the value added is negligible. Ask a probing and pertinent question and it can lead to a better and safer product.

The importance of the act of asking questions is underestimated. It’s not well taught. For the most part technical experts learn to do this on the job. From one project to the next they develop a set of approaches based on experience. Members of Administrations/ Agencies/Authorities have a great privilege in that they can expect their questions to be answered in full.

There’s a peer-to-peer relationship. To ask an effective question, technical experts on either side of the table don’t have to know everything the other knows. What is needed is a mutual respect and a sufficiency of command of a subject. Being able to pinpoint a gap or omission or inadequate coverage of a subject, or even waffle and evasion requires an intelligent and determined person.

Dead End

It’s been said as a joke but “Steve Barclay moves seamlessly from pretending Brexit is going well to pretending Boris is doing well” rings too true. This is a reference to Conservative MP and Minister Steve Barclay moving his desk into No. 10 Downing Street. Questions are being raised over how Johnson’s new Chief of Staff will manage more than three jobs.

Barclay will have a desk in No. 10, the Cabinet Office and his constituency. The Heisenberg uncertainty principle may come into play in that no one will be entirely certain where he is at any moment in time. It has been said that this is deckchair rearrangement of the highest art.

When a premier or Cesar[1] goes bad a blindness afflicts them completely. This is often aided by those in their immediate circle of influence. They are protected from reality by a shield wall of group think. So it’s right to ask, in the fullness of time, will Johnson be found playing the fiddle in the safety of No 10 Downing Street as the country burns (metaphorically speaking) around him. If he hangs on long enough this seems highly likely, given all the indications.

Barclay’s Brexit credentials are extemporary. He’ll certainly be using every opportunity to make the European Union a scape goat for whatever disasters are coming next. Public blaming has become the political tool of choice amongst Johnson’s shrinking cabal. A wide range of targets have been used. The Conservative party’s list is long: the media, foreigners, immigration, judges, courts, police, markets, industry, workers, civil servants, the voters, and most unsurprisingly anyone who voted “remain” in 2016 have all been under attack.

Johnson’s Government will continue to spin deeply misleading and often untrue statements to lift the spirits of its supporters. At the same time the smoke screen will anger and insult the rest of us.

A growing number of commentators agree about the inevitability of Johnson’s fall. But it’s not at all clear how he will be ousted, the timing or who is in line to take over the role of Prime Minister. Now, if this was classical Rome a violent act would be being planned at this very moment. In 21st century, Britain a public verbal evisceration and the movements of grey men in dark suites are probably on the cards.

As we pass into the next era there will be so much wreckage left by Johnson’s Government it’s going to take a mighty long time to fix it up. It’s possible to imagine a better Government. One full of hope and ambition but will they be first burdened with sorting out one hell of a mess.


[1] https://www.worldhistory.org/Nero/