Close Calls

Managing Risk and Resilience in Airline Flight Safety

C. Macrae

• Publisher: Palgrave Macmillan
• Year: 2014
• ISBN:
  9781137376121
• Topic: Negocios y empresa
• Subtopic: Gestión

Drawing on extensive and detailed fieldwork within airlines-an industry that pioneered near-miss analysis- this book develops a clear set of practical implications and theoretical propositions regarding how all organizations can learn from 'near-miss' events and better manage risk and resilience.

1

Searching for Risk and Resilience

“Close Call”. The term is redolent of the lucky escape, the close brush with disaster, the narrowly avoided catastrophe. Close calls don’t come much closer than on the morning of 21st November 1989, at London’s Heathrow airport. Flying blind in thick cloud and fog, relying on instruments and struggling with bouts of food poisoning and the notoriously tricky old ‘Sperry’-type autopilot, the crew of a Boeing 747 began their final approach. Breaking through heavy cloud just seconds before touch down, they made the gut-wrenching realisation they had drifted way off the runway centre-line, out over the airport’s perimeter fence. Punching the engines to full go-around power to abort the landing, the aircraft lumbered away, clearing the luxury Penta Hotel with little more than twelve feet (3.65 metres) to spare, sending staff and guests screaming into the street. Near-misses don’t come much closer. Nothing but providence and a few feet separated hundreds of people from an horrific catastrophe.

Dramatic events that place hundreds of lives in the balance are rare in commercial aviation. But thanks in part to striking moments such as this, the idea of learning from close calls and near-miss events has become deeply embedded in the culture and practice of airline safety management. It is an idea that has spread far and wide. Analysing and learning from near-miss events and operational incidents is now a central component of risk management practice in industries as diverse as healthcare, nuclear power and banking. At one time, only the most costly and harmful accidents were subjected to intense investigation. Now all manner of procedural mishaps, human errors and operational defects are routinely catalogued and submitted to in-depth analysis and investigation. Well-established incident reporting programmes can collect tens or even hundreds of thousands of reports each year, each one capturing a fleeting encounter with risk. These provide organisations with countless opportunities for uncovering risks in their operations and for improving safety. But, in practice, investigating, analysing and learning from incidents is rife with complications and difficulties. Transforming incidents into improvements confronts some of the deepest and most fundamental challenges of risk management.

When organisations take safety seriously, risk managers can soon find themselves awash with reports of errors, anomalies, near-misses and failures that are diligently filed by personnel from around the organisation. Some of those incidents may have very serious implications for safety, but many will not. Most operational incidents reported to risk managers involve only minor defects and fleeting disruptions: the occasional mishaps, complications and fluctuations that are inherent to all organised human activity. But in some cases, the underlying risks and the potential consequences can be catastrophic. Analysing incidents is therefore challenging and consequential work: the stakes are high and signals of risk are weak and ambiguous. Failures to identify and address risks at this early stage of risk management are particularly insidious. They allow risks to remain dormant and hidden deep within an organisation. When early warning signs are missed, people simply may not realise that certain risks exist in the first place – until they are dramatically and catastrophically realised. Interpreting and learning from incidents therefore depends on close calls of another kind: fine-grained judgements to determine where safety is satisfactory and where it is troubling, and which weak signals of risk matter most and should be investigated, and which should not. The art of risk analysis is not simply knowing what to look for, it is also the art of knowing what to overlook.

This book is about the practical work of risk management and the practical challenges that are inherent to analysing and learning from incidents, errors, failures and close calls. Specifically, this book is about the practices of airline flight safety investigators. Flight safety investigators are responsible for overseeing the safety of airline operations and ensuring that risks to flight safety are properly identified, understood and addressed. They are a special breed of risk manager and belong to a distinct technical and professional community with roots stretching back over a hundred years to the earliest days of formal air accident investigation. Nowadays, most flight safety investigators work in commercial airlines and much of their work focuses on assessing and investigating relatively minor flight safety events, reports of which are submitted in their thousands by airline personnel.

This role places flight safety investigators at the sharp end of risk management. They work in a context in which the deep interpretive challenges of risk management are particularly pronounced. In large airlines, front-line operational personnel can report tens of thousands of safety incidents each year. Each of those incident reports is extremely brief – often little more than a one-line description with some additional geographical and technical data. Typical incident reports merely highlight, for instance, that “flights A2490, A2940 and A2840 all operate from the same station at the same or similar departure times, which causes call-sign confusion”. Or that, “during pre-flight checks, the wrong departure route was entered into the flight computer and the error was only noticed and corrected after take-off”. By definition, these are reports of transient and fleeting events that have typically resulted in limited – and usually no – adverse outcome. A defect was discovered or an error was made, and then corrected. Investigators must trawl through these incidents to work out what they mean and what their implications might be for flight safety, all the while looking for new risks and remaining attentive to the early and weak signs of emerging threats. This work requires extensive and deep technical expertise. It also requires creative thinking, a deep index of suspicion and a healthy – or perhaps unhealthy – dose of curiosity.

Close calls involving jumbo jets and luxury hotels provide clear signals of risk, and naturally provoke intensive investigation and improvement efforts. But such events are extremely rare. The routine stuff of close calls is no longer a dramatic brush with catastrophe. Instead, the majority of events reported to investigators appear, at first blush, to be rather humdrum and mundane moments of organisational life. ‘Distant misses’ or ‘far calls’ might be more appropriate descriptors. The consequence of near-miss events becoming more distant and risk management becoming more precautionary is that warnings get weaker and more equivocal. The early signs of emerging risks are rarely self-evident, and the most serious and challenging risks typically lie at – or just beyond – the limits of current knowledge. Signs of new and emerging risks must be actively interrogated, pieced together and made sense of by investigators. To complicate matters further, safety investigators, like most other risk managers, have no executive control or direct authority to address risks. They provide independent oversight and impartial guidance, and so are separated from operational and executive functions. As a result, investigators’ practical strategies for managing and addressing risks are almost as subtle and nuanced as their strategies for identifying and assessing them.

This book, then, is about the practical work that is done to analyse, learn from – and make – close calls in safety improvement. It explores how operational incidents, failures and errors are interpreted and analysed in practice and how some come to be defined as risky whilst others are deemed acceptably safe. It examines how the earliest and most tentative signs of risk are identified and extracted from a mirky sea of anomalies and defects. And it analyses how knowledge is produced and practices are improved by transforming small moments of organisational life into signals of risk, around which wide-ranging activities of investigation and improvement are then organised. Flight safety investigators engage in a continual search for risk and resilience: this is the story of that search.

Making sense of safety

Risk has become an organising feature of modern industrial life. Ideas and ideals of risk management are embedded in a proliferation of risk management standards, safety improvement models and error analysis methods. Whilst risk is a staple of both professional and academic discourse, the practical nature of the work actually involved in interpreting and managing risk is more often assumed than explored. The practical work of analysing and addressing risk can remain largely invisible to the regulators and executives who are responsible for assuring the safety of their organisations. It often remains invisible in much of the research literature, too. Yet if organisations are to improve their ability to manage risk and safety, it is first necessary to understand the practices and the practical work that underpin these tasks. This requires up-close, prolonged and in-depth study of the situated practices, practical theories and analytical tactics that are employed by risk managers to make sense of and address organisational risks. We need to make sense of the practical work that risk managers do when they themselves make sense of risk and safety – and that was my purpose when I began this research.

Over the course of four years I observed, interviewed and worked with a group of airline flight safety investigators to understand the work they did and the shared knowledge and conceptual tools that they found useful. My focus was on understanding how flight safety investigators monitor, identify, analyse and manage risks to airline flight safety. My principle aim was to understand the interpretive work that is involved in identifying and understanding risks and organising safety improvement. I wanted to understand how flight safety investigators interpret the masses of safety incidents that are reported to them, how they use those incidents to identify and uncover potential risks to safety, how they analyse those risks and monitor safety and how they work to coordinate investigations and oversee improvements. As such, my attention focused on the cultural practices, the cognitive work, the conceptual frameworks and the shared social representations, ideas and models that underpin and shape how investigators analyse risk and improve safety. That is, my focus was on making sense of safety.

How experts interpret and make sense of safety is central to how risks get managed – and whether certain risks are even noticed and understood in the first place. When the interpretation and analysis of risks goes awry in organisations, risks can be inadvertently neglected or ignored. Effective risk management is the art of continually identifying and addressing the most pressing set of problems threatening safety. It is also the art of knowing what to overlook. Or, to put it another way, the most fundamental challenge of risk management practice is knowing “which aspects of the current set of problems facing an organisation are prudent to ignore and which should be attended to, and how an acceptable level of safety can be established as a criterion in carrying out this exercise” (Turner, 1976a, p. 379).

Investigators, like all risk managers, are confronted with masses of safety-relevant information and are faced with the imperative to act early and often, before risks are revealed by major organisational failures. But data on risk do not interpret themselves. In modern, complexly hazardous organisations like airlines, risks are rarely self-evident. One of the core challenges facing safety investigators is therefore interpreting and making sense of incidents and identifying the underlying risks that these may point to – challenges that are amplified and particularly pronounced in the setting of airline flight safety oversight. In the course of their daily work, “managers literally must wade into the ocean of events that surround the organisation and actively try to make sense of them” (Daft and Weick, 1984, p. 286). Risk managers face this challenge in the extreme, and this book is about how flight safety investigators work to meet this challenge.

To understand how investigators analyse, improve and make sense of safety, I focused on understanding their situated practices of risk management as they actually conducted their day-to-day work. Studying practical work in its organisational setting is notoriously challenging. It requires detailed analysis of the organisational context, social structures and conceptual and material resources used in practice. It also requires attentiveness to the cultural, cognitive and interpretive processes that underpin routine activities (Hutchins, 1996). Moving away from front-line personnel such as – in aviation – pilots and engineers, practical work takes on a less visible form, being more about analysing and interpreting than operating and acting. Studying how investigators analyse, make sense of and act on risks is particularly challenging due to the subtle nature of interpretive work. Interpretation and sensemaking involve active, effortful processing and social interaction. Sensemaking – literally the processes of making sense of situations, data and events – involves building a coherent account by combining the information, evidence, theories and knowledge at hand (Weick, 1995; Maitlis, 2005). Active processing and interpretation are typically occasioned by things that are out of the ordinary: “sensemaking begins with the basic question, is it still possible to take things for granted? And if the answer is no, if it has become impossible to continue with automatic information processing, then the question becomes, why is this so? And, what next?” (Weick, 1995, p. 14).

The work of risk management is focused on understanding failures and uncertainties: two common triggers of sensemaking. Efforts to make sense are commonly provoked by problems, gaps, puzzles, novelty, ambiguity and surprises – when things can no longer be taken for granted and when people’s sense of the familiar and routine has been shaken. At core, sensemaking is a process of identifying, bracketing and labelling certain things as relevant and worth attending to and then relating those things to existing concepts, knowledge and broader frames of reference to work out what they mean. Those broader frames of reference may be past experiences, memories, stories, professional standards, formal models or company procedures. Interrelating moments of experience with frameworks of knowledge is at the heart of how people interpret events and make data meaningful. These processes are inevitably social – if only because the frames of reference that people draw on are the products of previous collective activities, social communities, organisations and prior interactions (Wenger, 1999). The nature of expert practice, then, needs to be understood as more than merely doing, behaving or acting. Rather, practice “is doing in a historical and social context that gives structure and meaning to what we do” (Wenger, 1999, p. 47). To understand how professionals work, it is important to understand what knowledge they draw on and how they put that knowledge in practice. Put another way, “if you want to understand the essentials of what accomplished engineers know, you need to look at what they do as well as what they possess” (Cook and Brown, 1999, p. 387).

In this book, my focus is on what flight safety investigators do, what they know and how they put that knowledge into practice to manage risk and improve safety. This study took me deep into the practical world of flight safety investigators and allowed me to lift the lid on their work. To explore this world I used a range of methods over several phases of fieldwork. These ranged from short interviews, critical incident reviews, structured group discussions, in-depth interviews and working with investigators day-in, day-out for months at a time. During this time I spent some 400 hours systematically observing their practice, observed and discussed the analysis of 464 flight safety incidents, sat in on five different forms of safety meeting, including board meetings, team meetings and operational reviews, and conducted 39 lengthy and iterative in-depth interviews (Macrae, 2007; 2009). I studied the work of 26 flight safety investigators, at various levels of seniority, working across seven different organisations. My work was iterative. Each stage contributed to an emerging and evolving picture of practice, which set the focus for future stages of work. These methods allowed me to conducted research “in close rather than from the armchair” (Weick, 1995, p. 173). I listened to investigators’ conversations, observed their work, questioned their assumptions and worked with them to refine and elaborate my emerging explanations of their practice. I came to learn about the challenges they faced, the tactics they employed to deal with those challenges and the fundamental assumptions, conceptual tools and practical theories that shaped their work, their thinking and their management of risk. My analysis rigorously followed the tenets of the constant comparative grounded theory method, which seeks to produce useful, relevant and coherent theories of organisational life that are well-grounded in empirical evidence (Glaser and Strauss, 1967), and my methodology was ethnographic (Emerson, Fretz and Shaw, 1995; Crotty, 1998) in which, quite simply, I sought “to conduct informal interviews in industry, to participate in industrial life, and to ‘be around’ as industrial life unfolds” (Turner, 1971, p. 136).

My work was conducted in five airlines and two state air safety agencies, though I primarily focused on the work of flight safety investigators in large international airlines. All of these organisations employed specialist flight safety investigators whose primary responsibilities were analysing and responding to flight safety incidents. Five of these organisations were based in the UK and two of them in its linguistic and cultural cousin, Australia. These organisations were chosen to allow me to challenge, test and elaborate my emerging theoretical account of investigators’ practice. They were selected both for their similarities and differences in terms of the safety management principles and tools being used, their operational activities and the linguistic and regulatory frameworks they operated within. My focus was on producing well-grounded theory that was recognisable and useful to the practitioners involved, so I regularly engaged with flight safety investigators to invite challenge and comment on my emerging explanation of their practice. Nonetheless, as with all ethnographic explanation, this account is necessarily my working theory of their working theory.

Well-grounded theory interrelates the particular and the general, the practical and the theoretical. Throughout this book I liberally show the practical thinking and the work of flight safety investigators in order to richly illustrate both their working theory – and mine – and to deeply ground my analysis in the practical world of flight safety management. When the direct words of investigators are presented they are either indented and set apart from the main text, or are marked in “double quotation marks”, and referenced with an anonymous safety investigator (Si) code. These codes provide a degree of transparency regarding the relative sources of the fieldwork data being presented, while ensuring anonymity: each code refers to a participant involved in a specific phase of my research, and not to a specific individual investigator. Throughout my analysis in the chapters that follow, quotes in ‘single quotation marks’ are indirect quotations, being either common terms used by investigators or comments that were not recorded verbatim in my fieldnote or interview transcripts (e.g. Emerson, Fretz and Shaw, 1995). To provide further anonymity to the investigators and the organisations involved in this research, a range of technical details and names have been altered or disguised in all of the examples, vignettes and incidents presented.

A reasonable question at this juncture might be – why airline flight safety investigators? There are a number of reasons. Airlines represent one of the most technologically advanced and one of the least forgiving operational environments that exist. But they are also extraordinarily safe. This is in large part due to a well-developed infrastructure of safety oversight that spans regulation, design, manufacture and operation. It is also because so much effort is put into analysing and learning from failures. Accident investigation has been formally conducted for over a century and incident analysis has been deeply established in aviation for decades. Flight safety investigators have been at the forefront of these movements. Investigators represent a long tradition of safety management and a well-established professional community. Yet there is also surprisingly little wider understanding of the practices and the practical work of flight safety investigators. This is despite airlines having become something of a touchstone in the world of safety and reliability. Aviation is commonly held up as an exemplary case, and models and metaphors from airline flight safety are being increasingly and widely applied in other industries. Many of those models and metaphors are ...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Foreword
• Preface
• 1 Searching for Risk and Resilience
• 2 Airlines, Incidents and Investigators
• 3 Understanding and Interpreting Safety
• 4 Analysing and Assessing Risk
• 5 Overseeing and Monitoring Safety
• 6 Identifying and Constructing Risks
• 7 Improving and Evaluating Safety
• 8 Organising Resilience
• References
• Index