Lessons from Aviation Psychology: The Importance of Competencies and a Broader View of Human Factors with Aleksandra Kapela

Feb 19, 2026

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In this episode of The Safety Guru, we’re joined by certified aviation psychologist Aleksandra Kapela for a deep dive into aviation psychology and human factors, exploring what other safety-critical industries can learn from aviation. Aleksandra shares how modern thinking on human factors has evolved, emphasizing the importance of understanding the environment in which we operate, as well as the capabilities and limitations of the human brain. She breaks down the importance of identifying core competencies and explains why competency-based training and assessment (CBTA) is essential for preparing individuals to perform effectively in unpredictable, safety-critical situations and how these principles can be applied across a wide range of industries. She also explains why a broader, more holistic view of human factors is essential for improving safety performance and building sustainable safety cultures where people feel supported, are encouraged to speak up, and perform at their best. Don’t miss this informative episode packed with valuable lessons from aviation psychology!

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Real leaders leave a legacy. They capture the hearts and minds of their teams. Their origin story puts the safety and well-being of their people first. Great companies ubiquitously have safe, yet productive operations. For those companies, safety is an investment, not a cost for the C-suite. It’s a real topic of daily focus. This is the Safety Guru with your host, Eric Michrowski, a globally recognized ops and safety guru, public speaker, and author. Are you ready to leave a safety legacy? Your legacy success story begins now.

Hi, and welcome to the Safety Guru. Today, I’m very excited to have Aleksandra Kapela with me. She’s an aviation psychologist and human factor specialist. So, Aleksandra, first, as we get started, that’s not a common thing to be an aviation psychologist. So, I’d love to hear a little bit about how you got started, what you do, and the passion you have around this space. Let’s start there.

Sure, absolutely. Thank you very much, first of all, for having me. It’s a pleasure to be here and talk about such important topics. In my stories, usually in aviation, the story goes the same way. People, they fall in love with flying first. They become pilots, cabin crew, and engineers, and only later do they start becoming interested in safety, human factors, or psychology. But for me, for me, that was the other way around. I always knew that I wanted to be a psychologist. Long before aviation entered my life, I was fascinated and fell in love with the human brain. So, behavior, decision making, neurology, and especially human potential. Why do people act the way they do, how they perform under pressure, and how the environment can unlock their potential or, let’s say, limit it? That’s why I started the master’s programs in psychology and human resource management. I knew quite early on that I didn’t want to be a clinical psychologist or psychotherapist. I wanted to work with people and organizations in real, complex environments, helping them understand how and why this behavior might emerge and how systems can support them in that.

Aviation came into my life almost by coincidence. It was supposed to be a summer job at the local flight school to try something new. My friend, he was working there at that time. When I stepped into that environment, I fell in love with the industry as well. I think mostly with people at the beginning. But even more, later, I became fascinated by the safety element and safety culture. Sure. In such a critical, safety-critical domain, when a decision is made, they matter every single day. Actually, I assume that psychology and human factors would be fully embedded. I imagine that at every flight school, not to mention the airline. They would have at least one aviation psychologist supported by a team of human factor specialists. But that was a big surprise that it wasn’t the case. Even though aviation, compared with many other safety-critical industries, is usually thought to be really advanced in terms of safety awareness. I quickly realized that there was still quite a big gap between what we know today in modern psychology, neuroscience, and behavioral psychology, and how stress, attention, decision-making, and the human brain actually work, and how systems are designed and managed in the industry.

That’s when I started to look into how you can become properly qualified in this field of aviation psychology. I discovered that it is a really small, highly specialized discipline. Globally, there are only around 100 officially accredited aviation psychologists with a bit larger group of human factor specialists, of course, as let’s say, the entry requirements are a bit less demanding, you don’t need to be a psychologist. Becoming accredited required a lengthy certification journey, but it allowed me to work exactly at this intersection of psychology, safety, and operations. Today, I work in a few, let’s say, complementary roles. I run my own company, My Wingman, which focuses on supporting airlines and flight schools from the human side of safety. So, competency-based training and assessment, leadership development, instructor support, and well-being initiatives are directly linked to operational performance. At the same time, I also work as an Associate Aviation Psychologist with Symbiotics, a company known for assessment and selection solutions. Along with that, a large part of my work involves speaking and teaching, including delivering speeches, workshops, and training programs for leaders, instructors, and operational teams, mainly in Aviation but also in other safety-critical industries.

I’m also a ground instructor, so I work with students, which I really enjoy. And recently, I’ve been working on a book about Human Factors in Aviation, which is a very big project that is still a bit in the making. So, the book is still with the editor for the final editing. But this is a very exciting project I’ve been working on for the last 2 years.

Interesting. I’d love to start with human factors and really a modern perspective on what is happening in that space, when we’ve talked about it before in terms of capabilities, limitations in your mind, and the environment. Tell me a little more about how this space has evolved.

The modern view of human factors has led us to a bit more uncomfortable truth: the human brain is incredibly capable but also very limited. Sure. As its core, the modern human factor starts with this shift. Instead of asking what’s wrong with the person, why something happened, we ask what was happening inside their mind and how the environment also shaped what was possible in that moment. Because it’s really easy to say what we would do from our couch, but actually, in a specific moment, in a specific situation, with the specific limitations and capabilities of one’s mind, that might be very different. Now we focus on the capabilities and limitations of a brain as such, but also of a person at the moment. We know, for example, that attention can be our biggest help, but also our biggest enemy in stressful moments and in specific environments. We try to blend together the person, those limitations and capabilities, but also the environment, and also the system that the person operates in, which is really important. We have this systemic approach now, so we don’t look at individuals only, but we look at all those elements that made the situation happen in this specific scenario.

Somebody else or in a different environment could behave in a different way or maybe the same way. This is something that we always need to check.

Rear view mirror, once something happens, a more holistic view of what will occur, how can it practically help proactively? To ensure we act on the environment, we act on capabilities and limitations before something occurs.

Basically, if we take this more holistic perspective, then we are able to actually change things for the better for the future. If we would only focus on, let’s say, for example, in aviation, we’ve used to focus on how we can improve the aircraft for this situation not to happen again? Let’s say a certain switch was connected to this situation. How can we update or redesign the switch to help in the next situation? The problem is that the situations are so complicated that we will never be in the same situation again. Even though we replace the switch or we redesign something, which, of course, is also one of the approaches that we should have, and of course, improve that and upgrade as we can. But also, if we only hope that after changing this one switch, the situation will not happen again, or the bad situations will not happen, then this is a bit of false thinking. We need to understand how complex it is. We need to understand that things are happening both inside and outside. If we focus on this holistic approach, it’s also easier to think, even with changing that one switch of thinking, okay, but if somebody else were working with that switch, would that help them if we redesign it?

Or if this person is in this and this environment, in this company, let’s say, even in this culture, would that help them as well in the future? It helps people to rethink and redesign bigger systems. Also, it helps us educate not only system operators but also leaders and authorities, so they understand that a single change can make a big difference. That’s why, as we understand people more now and gain more knowledge about how we function and the environment, we need to use this knowledge. We need to use these findings, of course, slowly but to help improve safety and change the situation for the better in the future. So, not to add more hours, for example, in case of aviation training, but try to focus, okay, what we can change that actually, regardless of the hours, can help in the future in a similar setting, in a similar situation.

Is there anything that can be done, if I’m thinking particularly of the capabilities, but also some of the limitations, proactively from competencies development, or in terms of assessing competencies as well, for those circumstances that may exist?

Absolutely. This is one of the biggest concepts we focus on right now: competencies and some behaviors connected to them. So, they come out of our competencies. This is really important to focus on at the very beginning because, again, as I mentioned, we can add more hours, more training, more education in different industries. But again, if somebody had a low level of certain competencies, they would, regardless of the training, their knowledge, they would not be able to cope with a specific situation. If the situation becomes more stressful and more complicated, they need to adapt to this specific situation that might quickly evolve into a change. In that way, competencies and this whole approach of competency-based training and assessment, or CBTA, now focus on how we can improve human beings at the beginning. Sure. For them to be able to behave in a situation that we cannot predict. In the past, we tried to predict every possible situation, and we failed in that because those environments, even automation, everything becomes more and more advanced and complicated. One thing can change the situation that we couldn’t predict. Instead of doing that, we now shift, and we try to answer a case.

If this person had those competencies on a very high level, then it might actually be easier for them to cope with any situation. We don’t have to focus on those situations so much, but we focus on people who are capable, within their limits and capabilities of their brain, to react to different situations in different settings with different people. That’s why we first focus on those competencies. Those competencies are, there might be also a bit more technical, but we focus even more on those non-technical aspects. We focus on things that we used to talk about already in the case of human factors. But some of those things we know are actually. We are able to improve them if we know how to work on them. For example, decision making, for example, problem solving, communication, and workload management, those aspects, we know that if we have the right tools and also tools to assess them at the very beginning, and then if it improved, then actually they are proven to be those barriers that actually can stop this bad situation from continuing to happen. Now we focus on, okay, if we know the entry level of someone’s, let’s say, communication skills, then I know this level, that’s the first step.

Then I can, with the right tools, try to improve this. In the future, this person, despite stress, despite a very dangerous situation, will still be able to communicate with others, even though the possibilities of their brain would narrow their attention and their memory. Still, they would have the communication on such a high level that they would be able to communicate, even if the situation is very demanding. We know that in those safety-critical environments, proper communication with your teammates, with some people who might be responsible for the next steps, for example, is crucial. So very often this communication would be the first part that would be really affected by the stress, by this very demanding situation. Because this is a natural tendency of our brain. If we have a very stressful situation, we need to limit our attention; we need to limit what we say to others in order to be able to survive. In that way, if we focus on communication skills despite the stress, despite different problems that might occur, then we keep this relatively high level of communication, even though our brain and the situation want us to maybe limit this ability a bit.

That’s why we focus now on those core competencies, as we call them, because we know that also for the success stories that we have. Sure. Of course, in aviation, those success stories are really spectacular, let’s say. But for those stories, we know that those individuals who saved the day had a very high level of those competencies. In that way, we need to focus on this positive safety approach, as we call it safety to approach. We focus on improving the positives instead of trying to limit the negatives.

Sure. In aviation, you use the example of communication. In many cases, you have a job that is, for the most part, fairly routine until something goes horribly wrong. Then, as you mentioned, high intensity. If you think about the Air France incident where autopilots disconnect, all sorts of signals are giving you contradicting information, and you’ve got to process. Communication and stress levels are incredibly high, and you’ve got very short periods of time to address the risk in front of you. In a lot of other businesses, a lot of other industries, sometimes that difference between routine and high stress isn’t as pronounced, but in some cases, it might still be. How could some of these principles translate to other industries to still help? As you mentioned, communication. On a good day, you could be a very good communicator, but in that peak moment of stress where you really need that communication, that’s where you need at next level performance.

The beautiful and also problematic thing about our brain is that it cannot really recognize the settings that we’re in. In that way, it doesn’t matter really if we are 30,000 feet in the air, and anyone would say that that’s a really dangerous situation if something happens. Or it can be at your workplace, at your desk, but something very suddenly increases your stress level. For our brain, that would be the same situation. Very basic instincts and very basic reactions, they start to happen. We have our fight or flight response that is still really, really strong, even though we don’t have to run away from a lion anymore. But still, our nervous system doesn’t understand that. It doesn’t really matter if it’s a situation in the air or it might be a situation, let’s say, in the operating room. Still, this high peak of stress would narrow our possibilities in the same way. Our brain needs to be really focused on the basic things to survive. That’s why those higher functions, let’s say, like keeping the attention on different sources or communicating with others using complicated sentences, are something that first would be just raised.

In that way, for example, in the case of attention, I think it’s really relevant for different safety-critical domains that you need to keep your attention at a high level. You need to be sure that you’re not making any mistakes. In that way, your attention really needs to be at a high, highly functioning level. In that way, it’s really important to train those abilities. No matter what stress hits you, you can still maintain this high level of performance and teamwork, for example, because this is another competency that is pretty core. Being able to work within a team, which is, of course, connected with some other competencies. They all relate to each other. But most of the safety-critical environments need the same competencies. They need a high level of attention and situational awareness. They need communication, teamwork, and the ability to solve problems and make good, timely decisions. Of course, aviation is the industry that is the most, let’s say, spectacular in that way. But if you imagine someone working in any other safety-critical industry, they need the same competencies. But what would be different is the behaviors, so how they perform or how they use those competencies with specific behaviors.

The pilot would need to behave differently, and let’s say the surgeon would need to behave differently, but they would still need to use, let’s say, the same source and competencies. Of course, I focus mainly on aviation, but I also consult on other industries as well. I use my experience from aviation, but actually, I see more and more that it’s really the same thing, the same elements, because our brain is the same. It just needs to be used differently. That’s why we have certain training. Let’s say this technical part and the educational part are what will be different. But how we act in this really highly stressful situation is something that would be the same across different domains and industries. If we just lack those competencies, our performance will be affected. It doesn’t matter what industry it is. We aim to achieve the highest possible performance to increase safety. To do When you do that, your capacity needs to be enough to handle that situation. Of course, there are some other things, like psychological safety, that need to be at the proper level.

Your, let’s say, physical abilities need to be at the proper level. But we see that those abilities of your brain, in terms of competencies, are one of the most important things to be able to perform at a safe level in any situation that you need to perform.

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CBTA really helps us understand competencies that are needed, where I am at, and how I am progressing through different interventions, potentially?

Yes. They also answered the question of why those limitations exist. For example, I might repeat the same mistake in my work, and I might have more training, more education. I will be more frustrated. Still, I would not perform well in certain situations. Sometimes, a very simple key for that is just to improve the competency level. If somebody were, let’s say, very good at, say, communication, again, but they would not be very good at decision-making. They might talk with others. It might help them with other competencies as well. But they still would not be able to make timely decisions, and this can sometimes be really critical for safety. That’s why it’s really important to know those levels right from the start. If somebody enters the training or a job environment. We, as people, would be responsible for training that person. But also, this person themselves would want to know what level of those competencies I have. Because very often people cannot realize that they wouldn’t think about it earlier, that they might have problems with certain competencies because they do quite well, they progress, they live in society, etc. But actually, those levels need to be a bit higher for that safety-critical work.

In that way, it is so crucial to know it at the very beginning, and then only you will benefit from that if you retest it. If you check it again, then you know if the person can progress, if you’re doing the right things in case of the training. And also, they start to feel more and more at ease. So, they might not realize that this is their issue, their problem that they have. But after a certain period of time, we see that people with a raised level of those competencies just feel better, they function better, not even in these very stressful moments, but daily. So, in that way, it gives them more space, more capacity to work with any situation that they face. If the CBTA is done well, the safety conversation also changes. We stop asking who made a mistake and what exactly happened in that situation. We also stop blaming individuals, but we start asking whether the system built the competencies needed to deal with what actually happened. To do anything. It worked both directions, we might say, because we know that people are not perfect, systems are not perfect.

But we try to find ways to increase both of those elements together. And by increasing competencies, we see that everything goes up.

And how does this connect with psychometrics? Because of the scenario you just shared, somebody who is good at communication, but may not be great at decision-making in a peak moment of stress. And so that could make you incredibly functional in many roles. In some functions, you can have the liberty of time to make decisions. For a pilot, you don’t typically have unlimited time in terms of that decision-making. How do we start checking around for a specific work environment, and how does that connect back to CBTA?

So, of course, in the case of CBTA, the last letter is A. So, this is the assessment. And this is more connected with how the competencies can improve. So, if we can learn, if we can improve them. In case of competencies themselves, it’s a bit easier work because if, let’s say, your baseline is okay, if you don’t have any disabilities, learning disabilities, or any, let’s say, disorders that would not make it possible to increase those levels, you can work with competencies. You can improve your competencies. If you have the right tools, if you know what to work on, you can improve them. Competencies are something that we use on a daily basis in different environments. This is something people sometimes do not realize they can improve if they work on it. It’s like with our memory. We can improve it if we don’t have any disabilities in that area. Sometimes we joke that it’s like a muscle we can just improve by working on it. In assessments, we don’t focus solely on competencies; we also consider other things, like personality or attitudes, which are a bit more core to people.

They are usually built from the beginning of our life, connected with how our nervous system is built. So, they are a bit more difficult to change. Regarding personality aspects, we can also check this. So, with the right tools, with the right assessments, we can check what traits, what, let’s say, tendencies you might have. This might make you better or worse in some specific environments or jobs. Let’s say there is one personality trait called conscientiousness, which is associated with people who like to be organized and structured. They like things. They like routine. This is something that is pretty core in you. People would be higher or lower on conscientiousness. In the case of pilots, for example, we like to have pilots who are high in case of conscientiousness because they need to work with routine most of the time. They need to pay attention to procedures, follow them, etc. They need to be organized, and everything needs to be neat. In that way, if somebody were higher on that trait, it would be easier for them to feel good in this environment.

If someone has a low level of conscientiousness, it doesn’t mean they cannot become a pilot, but it does mean they would just struggle, and that struggle would make them less able to perform well under stress. It will make them less able to train in case of their competencies as well, because those things just go together. For example, there are certain traits that, let’s say, a good accountant should have. I wouldn’t be a good accountant myself for sure, knowing my personality. If I were still trying to keep this job, I would probably be really frustrated, unhappy, and struggling with my performance. In some jobs, that would just make people unhappy. But in safety-critical industries, it’s really important to have people who are a bit better suited to this specific job. Psychometrics is one of the most, let’s say, misunderstood tools in safety-critical industries, I feel, because for some people, the word itself immediately triggers fear of labeling, discrimination, and being put in a box. But that fear is understandable because psychometrics has sometimes been used poorly, so not to use the right tools, not to use the results in the right way.

But when it’s used correctly, they are not about exclusion; they are about information. If we have this information, then, for example, we can place somebody who still wants, let’s say, they really want to be a doctor, but with those traits, they might struggle, they might be not so good, for example, being a surgeon. It would be better for them to work as some other type of doctor. In that way, and for example, for pilots, it’s maybe not best for you to work in an airline when the routine is there, and work is almost the same every day. Maybe it’s better for you to go to flying, which there is less routine, more changes, and a bit more risk. Some people need to have a bit more going on to feel good. That’s why it’s so important to check it at the beginning, not to spend a lot of money, a lot of time, and invest in something that might just be some concept that you might have in your head but does not really fit your capabilities and limitations. A big part of my work is also to explain that to people, that it’s not like yes or no.

It’s more than we need that information to increase safety, because if people who are not fit for certain jobs perform those jobs, it’s the first step toward unsafe acts in this environment. It’s not a verdict; it’s a map that we use for the future.

I think it also, to your point, if you’re going to be frustrated, unhappy in that work environment, that’s not an environment that’s conducive to your well-being, and also will create more friction in terms of the work in addition to some of the safety elements that you brought up. It can also be a vehicle to get to know yourself in terms of where your best fit might be.

Yes, exactly. If you’re more frustrated, a bit more stressed, then the first thing that happens is that your limitations come to the surface. If you’re angrier, sadder, or more frustrated, then you would simply make more mistakes. Then if you make more mistakes, you will be even more frustrated. Then you start to blame, usually people, they start to blame others rather than themselves, because this is what they wanted and why it doesn’t work. Also, in some of those industries, it is really difficult to stop or to say, I’m struggling. In that way, as you said, it is really connected to well-being because not only do you feel bad and angrier, frustrated, but you will have more problems with your family and friends. But also, it adds to that silence that if something is wrong with them or me, maybe I should just keep on going, but then I see that nothing is changing. So, my level of well-being is dropping dramatically, and I might not have a safe place to question that, to ask those questions. So that’s why it is so important to have this information at the very beginning. Sometimes, also what I’ve seen is for those different industries, especially if somebody young is starting in those industries, then parents, it is very important for them, for their kids to perform well and support their dreams.

But if everybody got this information at the beginning, maybe it’s time to rethink, maybe adjust a bit this path that you want to have, then eventually everyone would be happier, more satisfied, and their well-being would be higher. So, all those things that we do at the very beginning are not to make people’s lives more stressful or more difficult, but to make it less stressful and less difficult later.

Yeah. And on this topic of well-being, what other things can an organization do to create a really safe environment where people prosper from a safety standpoint?

That’s a really interesting topic because well-being is something that we hear quite a lot about now. We are more and more about well-being, well-being. We need to ensure that there is a healthy work environment. But what is most important about well-being is to understand it. Again, to understand how people’s brains work, what well-being actually is, and what levels it has, so you can create well-being programs or actions in your workplace. Very often, there is a well-being website, sometimes that is focused on well-being, but this is just like an end product. If there is no box-sticking exercise, when there is no understanding of what really makes people well in the workplace, then it might actually not change anything, but also make things even worse. What is really important is, first of all, that well-being is closely connected to what we call safety culture, as well as psychological safety in the environment. In that way, we might create a lot of things, yoga classes or any other things that should make people more relaxed. But when the workplace is not supporting this culture, nothing really will change.

The first and most difficult element is organization’s working with the culture of the culture. When people feel good about sharing things, especially things they may have done wrong, if they are not blamed for it but it is accepted, and people focus on improving it, they are thankful you share that. Of course, it might be connected with some more serious action as well. But what is really important is that you don’t feel this fear. You have this state of mind that you can talk about everything, about what was okay, but also what was not okay. In that demanding environment, people learn really quickly what is acceptable and what is not acceptable to show. If the safety culture in the workplace is high, then people will start to follow that pretty quickly. If the safety culture is low, people will learn very quickly that you can miss some things, you cannot report some things, and that’s okay. It is really important to understand what safety culture is and how it can be built. That is also, again, connected with the environment on the outside, but also with people from the inside.

What is, I think, most important is to start with education because people are not educated about their own well-being. What does it mean? What does it mean in this specific industry or company, in the training place? People, they need to understand how they might feel. They also don’t have to feel happy every day. But what is, let’s say, in the norm? Also, what they should do very quickly if they feel that something is not right is not wait; everything is open for them to share it. Again, that brings me back to competencies once more, because, again, people with a higher level of competencies deal with some well-being fluctuation better. If you have a higher level of communication and teamwork, then it’s easier for you to share something with others, to communicate it. But without a proper safety culture, you can have great levels of communication, but if you cannot communicate it, then nothing will change. Those are two things: safety culture in an organization. People from the top levels who will set this culture, who will understand that people need to feel good to be safe and to perform well. And then from the bottom, also for people to understand what Wellbeing is.

That is not just a nice word to repeat, but what does it actually mean, and what does it mean in my job? Because for different jobs, it might be connected with a bit different elements. Let’s say in the job of a flight attendant, being a bit lonelier in a sense of not having your family all the time next to you or a lot of people, a lot of crowds to share things with. This is also typical for this job. Again, if you understand that, and do you know what tools you have if something feels different? Also, if you have the right, again, personality and competencies to deal with this specific environment. Everything connects. That’s why this holistic view is really important, no matter if it’s well-being, competencies, or any other assessment, so anything connected with safety. We are only now starting to understand it. It is a bit more difficult now for us because we built those systems that were not built for that, for the holistic view. It’s more built for, again, adding more hours of training or improving one part of something. But now we need to learn, and we start to understand that only changing things from this holistic level can actually improve safety.

So, thank you so much, Aleksandra. We covered a lot of ground today from a modern view of human factors, as you said, that talks about capabilities, limitations, the environment, connects very well to the CBTAs and how do we understand competencies and how we can you give us a little bit more about how you get involved in this element of psychometrics, and is it the right fit? Are there better fits for you? And how that also links back to well-being, which connects back to what we talked about in the environment where we operate. So, thank you very much for joining us today to share some of your insights. Somebody wants to get in touch with you. What’s the best way to do so?

I would say the fastest way would be to contact me on LinkedIn. I’m there with my full name or try to reach me through my wingman site as well. But I’m on LinkedIn every day. I post quite a lot, also about human factors and safety. That would be the best way to contact me.

Excellent. Thank you so much, Aleksandra.

Thank you for listening to The Safety Guru on C-suite Radio. Leave a legacy. Distinguish yourself from the past. Grow your success. Capture the hearts and minds of your teams. Elevate your safety. Like every successful athlete, top leaders continuously invest in their safety leadership with an expert coach to boost safety performance. Begin your journey at execsafetycoach.com. Come back in two weeks for the next episode with your host, Eric Michrowski. This podcast is powered by Propulo Consulting.

ABOUT THE GUEST

Aleksandra Kapela is a certified aviation psychologist, speaker, author, and independent consultant specializing in human factors, safety, and competency-based training and assessment (CBTA) programs. She works with airlines, flight schools, and other safety-critical industries, supporting organizations where performance, decision-making under pressure, and human reliability are critical. Her work focuses on human potential, well-being, operational performance, and modern, evidence-based approaches to human behavior in complex systems. Aleksandra is the founder of MyWingman.eu and the author of an upcoming book on human factors for pilots and aviation professionals.

For more information: https://www.mywingman.eu/

Email: [email protected]

LinkedIn: https://www.linkedin.com/in/aleksandra-kapela/

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In this distinctive episode of The Safety Guru, renowned safety expert Dr Andrew Hopkins joins us to explore the critical lessons from the Boeing 737 MAX. Drawing from his latest book, Andrew unpacks a comprehensive analysis of its troubled history, uncovering flawed system design, organizational blind spots, and safety decisions that led to devastating consequences. He shares key learnings for boards and executives, emphasizing safety as a core responsibility and underscoring the importance of understanding and managing risk at the highest levels, while addressing how long-term safety performance is essential to sustainable business success. This information-rich episode delivers valuable takeaways on strengthening the role of safety governance, enhancing risk oversight, improving leadership accountability, and building safer systems for the future. Listen now!

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Real leaders leave a legacy. They capture the hearts and minds of their teams. Their origin story puts the safety and well-being of their people first. Great companies ubiquitously have safe, yet productive operations. For those companies, safety is an investment, not a cost for the C-suite. It’s a real topic of daily focus. This is the Safety Guru with your host, Eric Michrowskiy, a globally recognized ops and safety guru, public speaker and author. Are you ready to leave a safety legacy? Your legacy success story begins now.

Hi, and welcome to the Safety Guru. Today, I’m very excited to have with me Dr Andrew Hopkins. He’s Professor Emeritus at the Australian National University in Canberra. He’s written multiple books. So, Andrew, welcome to the show. Very excited to have you with me.

Well, thank you, Eric. It’s actually a pleasure to be talking to this particular audience, people who are either in the C-suite or sensitive to what goes on in the C-suite. That’s very much my concern as well. I thought I’d just say something about how I came to write this most recent book; The book is called Boeing: The 737 Max Crisis and Aviation Safety: The Perils of Profit-driven Engineering. The Perils of Profit-driven Engineering. That last subtitle really sums up what the book is about. So, the question is, how did I come to write it? Well, I’m a sociologist, and sociologists are interested in many things. I’m particularly interested in the sociologist community of organizations and how they operate, how they fail, and why they fail, and what leads them to behave in negative kinds of ways, in indeed negligent kinds of ways. That’s one of the drivers behind this book, is that professional concern. But there is another one, of course, that motivates me in all of much of what I do, because reading these accounts of accidents, of major accidents, such as the, well, this one, the Boeing accidents, and for the BP’s Deepwater Horizon, oil well blowout in the Gulf of Mexico in 2010.

All these accidents are characterized by big companies who are behaving in truly negligent ways, and they are pursuing profit above all else, and certainly above safety. They’re very careless with respect to safety, especially major accident risks, which rarely result in a major accident. But when they do, it’s major. It really is often life-threatening. They often are very focused on lost time injuries or other injury rate data because it is good data, and they can look at that and seek to drive that down. But they don’t pay attention to the really the major risks because for most companies, they seem rather theoretical and far off and distant. But the net result is when these accidents happen, one is overwhelmed by, I should say, I am overwhelmed by a sense of outrage that they were indeed so careless. That outrage is one of the drivers. It’s not a useful emotion in terms of creating a sensible analysis, an analysis which highlights what needs to be done, but I have to acknowledge it’s one of the drivers there in the background. Okay, so these books then that I write are all aimed at identifying lessons, particularly lessons that boards can learn from these accidents and this one, this accident is particularly useful from that point of view because there’s a lot that I can say and will say about the failures of the board.

But let me start with the story. Sure. We have these two crashes of the new Boeing 737 MAX aircraft in 2018 and 2019. The first one, in 2018, the aircraft had just taken off from an airport in Jakarta, actually. It’s irrelevant where they were because the location plays no part in this. Just taken off from the airport, and it was climbing away from the airport when suddenly the nose of the aircraft dropped, suddenly dropped, and it headed for the ocean below, steep descent in towards the ocean. Of course, the pilots didn’t understand what was happening, and they were terrified, and they worked hard to pull back on the to pull the aircraft back on course, back onto its normal rate of ascent, and they managed to pull the nose back up. One can imagine the sense of relief they felt, but straight away, the nose dropped again suddenly. It’s as if the aircraft had a mind of its own. They must have been totally bewildered by what was happening. Again, they fought to bring the nose back up, but again and again, the nose dropped, and it was like a It must have been like they were on a bucking bronco trying to control this aircraft.

It seemed set on diving into the sea. Finally, the aircraft went, and it dived at a very steep angle into the sea, killing everybody on board. Now, the same thing happened then, just four months later, another one of these aircraft, 737 maxes, taking off from a different airport. It was climbing away from the airport, and the same thing happened. The nose dropped, and a struggle ensued between the pilots and the aircraft to try and keep the nose up, and the pilots ultimately failed, and the aircraft drove itself into the ground, killing everybody on board. Now, of course, when two aircraft do this in quick succession, it’s clear there’s something very seriously wrong, and the regulators around the world grounded the 737 have MAX until further notice, and they remained grounded for two years until that problem was sorted out. What was the problem? There was a design failure. The MAX was just the latest model of the 737, each new model involves new design features, basically the same aircraft as first took to the skies in 1967, I think it was. It was the original model was… The original design was very old. It was a very good design.

It had served the Boeing and the traveling public well. But each time there was one of these one of these design modifications, it introduced the possibility of failure. There was a particular failure which was introduced in this most recent model in 2017, around that time, as this new aircraft was about to go into production. A new hazard was introduced. I won’t try and talk in detail about that hazard, except that it was a tendency to stall in certain circumstances. It was intended to stall. Sure. Stalling involves when the nose of the aircraft rises too sharply and the aircraft is trying to climb too steeply, it loses lift, and the aircraft will stall and fall out of the sky. This was a hazard which was introduced in the most recent design modifications. The engineers then in the design process, in the testing process prior to production, came up with a solution to how to deal with this. They introduced a piece of software. It’s always whenever you introduce These modifications like this, when you’re adding on something to increase the safety, these add-ons often introduce additional hazards of their own, and that’s what happened on this occasion.

This additional piece of software, it was designed so that it would automatically force the nose of the aircraft down if it detected that the nose was too far up and that the aircraft was about to stall. This would be totally automatic and be beyond the control and indeed beyond the knowledge of the pilots. The pilots were not told that the aircraft would behave in this way at all. But that’s the new piece of software which was sitting there in the background ready to swing into action. How is this software to be triggered? What would trigger it? Well, there’s a tiny sensor on the side of the aircraft fuselage that sensors what the angle of the aircraft is and whether it is approaching any dangerous angle. If it detects that that is the case, then it will send a message to the software and the nose of the aircraft automatically drops. It’s a very vulnerable little thing, very easily damaged. This is what happened in these two cases. In the first case, the aircraft, as it was taking off, hit a bird, and this damaged the sensor, and the sensor began to send through haywire kinds of commands to the software.

In the second case, I think there was a maintenance error on the ground just before the aircraft took off. Again, the sensor started sending through wildly inaccurate information to the software. That’s really the technical detail of what happened. But the point to notice about this was this whole thing dependent It depended on a highly vulnerable piece of equipment. It depended on a single point operating as it should. There is a principle in aircraft design that you should never be vulnerable to a single point failure. Yet this design, this design which they had introduced, was vulnerable to that single point failure. The question then is, why did the engineers allow this to happen? We’re now going to get into what I want to do look at the history of the company a little bit and talk about some of the forces that were at work on that company that led to this apparent carelessness by the engineers in this situation. Boeing had been a very successful company, and still is, of course. But in the early days, it started in 1916. It was started by engineers. It was owned by engineers. Engineering excellence was the absolute touch shown of everything they did.

They would never sacrifice engineering excellence to any other motivation. But around about the year 2000, there was a significant shift in Boeing’s approach to these matters, and they began to focus very much on shareholder return. That became the dominant criterion by which everything was assessed. What is the shareholder return? How are we maximizing shareholder return? In the process, engineering excellence gets downgraded. Engineering becomes how well we’re doing as engineers is a secondary consideration. That was a decision that was made quite consciously by the Boeing Board and the Boeing CEO. There was a bit of a problem, though, for them because the engineers were still in power, and the engineers were wielding too much power as far as the top management was concerned. Everyone was located in Seattle. The engineers, the top management of the company, all located in Seattle. The top management, the CEO, decided the only way to cope with this pressure from the engineers, because it was a conservative pressure. Safety always involves conservative decision making. Engineers were on the conservative side when it came to making a decision. The only way that the top management could deal with this was to move their location away from Seattle to Chicago.

To Chicago, right. So, the headquarters of Boeing moved. It then moved later, again, elsewhere. But this part of the story, they moved to Chicago where they were, I don’t know, it was a thousand kilometers away from Seattle. I don’t know exactly, but it’s a long way. In that way, they were cut off absolutely from any day-to-day contact with the engineers. Engineers didn’t have that direct access to the people at the top, which they previously had. The result was that the engineers ended up disempowered and unable to insist on engineering excellence. Their reporting lines changed. They reported to lower-level business managers, and their voice was muffled as a result of that. They were not heard at the top of the company. This was a very deliberate strategy. I think the CEO at the said, this has been a great engineering firm. We need to change it from being a great engineering firm to being a great business firm. That was the conscious state of mind of the top management. Now, Boeing was not alone in this, and we need to understand that other companies are doing the same thing. The other one that I’ve studied was BP and its blowout in the Gulf of Mexico, which I mentioned before, was attributable to the engineers being disempowered.

They had been disempowered. One of the lessons that BP learned was the need after that to re-empower them so that they would be heard and listened to. But the point is this was part of a more general change in the nature of capitalism. After World War II, capitalism developed in a way that took account of all quite a range of stakeholders, not just shareholders, but also passengers or customers. Customers, in this case, would be the airlines, workers. Government itself, government has an interest in the quality of what goes on because they draw taxation from these companies, and vendors, and lenders, all these people are stakeholders. The way capitalism developed and the way it was regulated was designed ensure that all these stakeholders’ voices were heard. But that attitude changed dramatically. It began to change with Ronald Reagan in the 1980s. The move was to move away from stakeholder capitalism to shareholder capitalism, where shareholders’ interests are paramount, everything else is secondary. That’s what happened. This is part of a much more general phenomenon. In many companies, and certainly in companies like Boeing, the way this was achieved was by setting in place a system of bonuses, very large bonuses, which the CEO and the very top managers received if they were entirely dependent on the share market stock price.

These were the so-called long-term bonuses. Long-term bonuses, they’re paid three years after they’re earned, depending on what the share price does. Sure. Of course, there are many other bonuses that operate in these companies, but it’s the ones at the very top that are critical because this drives the decision-making of the CEO and the top management. These long-term bonuses are very, very large. They’re worth 10 to 15 times the salaries of these individuals. There are massive bonuses which dwarf their salaries. They’re very effective keeping the attention of top management absolutely focused on maximizing return on investment. As I say, this has nothing to do with Boeing specifically, but it’s a universal phenomenon that was going on at the time. It leads to a loss. The top management absolutely lost their any focus on safety. In fact, many of them thought that safety was not their business. One of the interesting consequences of this is that it really places the regulator in a more difficult position. The regulator now becomes, if you like, almost the last line of defense against things going wrong in a catastrophic way. Regulators must be willing and able to exercise the power to ensure that these companies are not heading for disaster.

In this case, the regulator is the FAA, the Federal Aviation Administration. But FAA and regulators frequently, it was not adequately resourced. It was unable to carry out this new and more critical watchdog role that it had in this emerging form of capitalism. This was very relevant in the 737 MAX case because the FAA had to certify that this aircraft, this new version of the 737, was safe before it could go on sale, before it takes to the skies. How did it do this? Well, in the end, it had to rely on Boeing’s own engineers for the information which they would need to certify the aircraft as safe. Now, you can hardly imagine a more horrifying conflict of interest that these engineers are in. They’re under enormous pressure to speed things up so that the company can start selling these aircraft generating a stream of revenue. Enormous pressure to speed things up, on the one hand, from the company and on the other, the engineers who’d been appointed by FAA to act as that watchdog, they were under pressure from the FAA to ensure excellence was not being compromised. It’s an impossible conflict of interest. It’s unbelievably crazy.

That’s what was, I guess, one of the major factors which contributed to this accident. It meant that the FAA did not know anything about this single point failure when it certified the aircraft as safe. It certified the aircraft in ignorance of one of the most significant changes in the design at that point. Again, it’s a story. It’s not unique to Boeing, and it’s one from which we can all learn. Finally, then you might then ask, Well, what about the board? Does it have a role in ensuring safety? These boards are very far distant physically and in every respect from the day-to-day operations of a company like Boeing. But do they still have a role in relation to safety? Certainly, they do. The fact of the interesting thing is that this board, Boeing’s board, did not ever ask questions about the safety of the new aircraft. As far as it was concerned, safety was a responsibility of others, in particular, Boeing’s engineers, but also the FAA. The board was simply relying on the FAA certification to ensure that the aircraft was safe. As far as the board was concerned, the FAA was just another bureaucratic hurdle that had to be jumped.

They frequently ask, How’s the FAA going in relation to this certification? It’s an ongoing process that takes years, actually. How’s it going? But the only reason they were interested in what was happening with the FAA was that this was standing in the way of this stream of revenue which they were expecting as soon as that aircraft could take to the skies. That was their focus. It was not on, well, is the FAA discovering Is it covering any safety problems? Is it having difficulty with any aspect of the design? They were not thinking in those terms at all. Let’s ask the question, what should the board have been doing? What might the board have been doing? There’s some very important information that became available in this particular case, in the Boeing case, because of a particular legal action. The shareholders in Boeing sued the company on the ground that the board of directors had failed them. Now, this is a very unusual thing, and they sued them. This is a civil action for damages. The damages to the shareholders were that they lost share value.

Significant share value.

Yes, significant share value. Most of the actions that have come out of this crash, and others like it, are from people who were killed or their relatives, or their families who are demanding compensation for that damage. But this is about purely financial damages to the shareholders. They took this action, and they won. It was before a judge, and the judge came to the conclusion. The judgment says that the board had been entirely negligent with respect to safety. In some respects, dishonest, which is a very strong thing to be saying. This judgment actually went on beyond that to say, well, these are the things which it should have been doing and wasn’t doing. That’s why this judgment is so valuable, because it tells us it’s an authoritative statement about what boards should be doing.

There are several things that I want to talk about coming out of this judgment. The first important point that he made was that boards need to be skeptical. They need to be skeptical of the information which they’re being fed because as we all know, good news passes upwards in any organization quickly. The bad news follows way behind if it ever does. Boards need to understand that and must be willing to ask pointed questions and pursue those questions as far as they can. Skepticism was about the safety, about the certification process. That skepticism is a state of mind which boards need to aspire to and exercise. More generally, the attitude can be expressed as challenging the good news and embracing the bad news because the boards are constantly fed these reports which say that everything is okay, all our indicators are on track, etc. Boards who generally say, That’s great, good. What they should be doing is saying, well, tell us about these indicators. How reliable are they? Can we trust them? The moment you started asking questions about the reliability of the information, if they’d been asking, in this case, about FAA’s conclusion that the aircraft was safe, if they’d asked those more penetrating questions, they would have got to maybe had a glimmering of understanding of the incredible conflict of interest which Boeing’s engineers were placed in and how dangerous that was.

But they didn’t go anywhere near that. They didn’t challenge the good news and embrace the bad news. Now, embracing the bad news and looking for the bad news is a very important part of this state of mind because there are always warning signs before a major accident occurs. There are always warning signs, and I stress this is always the case, that things are not as they need to be. Things are not going well. Something’s wrong, and if something is not done about it, then a major accident is likely to ensue. The boards need to be on the lookout for this bad news. When they identify it, they need to explore it as far as possible, learn from it, and understand what needs to be done to deal with that situation. For example, they need to ask the CEO to pass through to them any information that he or she is getting from whistleblowers. They didn’t hear. There were lots of whistleblowers in Boeing, but the board never got to hear about them because the CEO and top management protected the board from that bad news. This is why this is such an important slogan.

It’s often put in metaphorical terms, the traffic light metaphor of green and red, of challenge the green and embrace the red. It’s a really simple idea, but powerful. It’s about state of mind the boards need to exercise. This board went nowhere near that. Some of the other things, the more detailed things that the board, that the judgment highlighted were that there was nobody on the board who had any aeronautical expertise, aeronautical engineering expertise. Nobody on the board who had any understanding of the fundament, the most serious risks, that safety risks, quality risks, risks that confronted Boeing in the manufacture of these aircraft. All boards need to have, said this judge, all boards need to have at least one specialist, someone who’s a specialist in the technology, in the risks, in the major hazards which confront the organization. This, by the way, these findings now by the judge actually echo a lot of conclusions that the authorities have come to elsewhere in other countries, particularly in the UK. These ideas have been understood for quite a while. So, boards need to have these kinds of specialists. Boards need to have subcommittees whose job it is to focus on these major accident risks which confront a major hazard company, a company which deals with major hazards, as this is the case with oil companies or aircraft companies or mining companies.

All these companies confront possibilities of catastrophic risks which can kill hundreds of people. Boards need to have subcommittees which specialize or focus on those kinds of questions and develop information about those which they can then pass on to other board members about how well those risks are being managed. It’s a way of directing at least part of the board to focus on these kinds of things. That’s another thing that the aspect that came out of the judgment, which is now being implemented. A lot of these things have been implemented in Boeing to some degree. Unfortunately, not completely, but to some degree.

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Another aspect of this accident, which is quite typical, is that when it happens, the companies try and blame the frontline operators for making mistakes. In this case, it’s the pilots. The concept of pilot error is the first resort of a company when it’s faced with this crisis. Indeed, the CEO of Boeing, after the first crash and questions were raised, the CEO was able to say, this was pilot error. There was nothing wrong with the aircraft. The aircraft is safe. If only the pilots had followed the correct procedure, this wouldn’t have happened. This is a very standard response that happens. What it betrays is a complete failure to understand the human factors that lie behind these accidents. Because it is true that the pilots were lost. They didn’t understand what was going on. There were some actions they might have taken which would have prevented that accident, but they didn’t understand what they were. They were so overwhelmed by what was happening to them that they weren’t thinking rationally.

It’s predictable that pilots in this people, human beings in these kinds of situations will not think rationally, will not stand back and say, well, what should we be doing? They won’t consult the manuals. They haven’t got time to consult the manuals. They will make mistakes which to the outsider seem irrational, and that’s certainly one of the things that happened here. But Boeing was actually very much at fault for the state of mind of the pilots because Here was this change that they’d introduced in the aircraft, this piece of software, which in certain circumstances would thrust the nose down. They’d introduced this, and they didn’t tell the pilots. In fact, they decided that the pilots ought not to know about this and shouldn’t know about this because it wasn’t necessary, they thought, Boeing thought. There was an economic reason for this. They said, if pilots don’t need to know about this. There’s nothing really new in this aircraft. They don’t need… Pilots will not need additional training. In particular, they won’t need to be trained on simulators, which is a standard form of pilot training these days, simulators on the ground. They won’t need that training.

Now, this was a major selling point to the airline industry because simulated training for pilots or retraining, as would have been required if this matter had been taken seriously, Simulator training is expensive. Because Boeing was able to promise the airlines that there would be no additional simulated training necessary, this was a big selling point, which when they announced that this new aircraft was going on the market was an important reason why they began to pick up orders. The result was that pilots were entirely unaware. They were entirely unaware of what was this new development. They had to go back, and they would have had to go back and try and work out, okay, in a crisis like this, this is what we do. We don’t know exactly what it’s all about, but this is what we should be doing. We should be canceling the automation on the flight and trying to fly the aircraft manually. Had they done all that, then maybe they would have avoided the accidents. But they weren’t thinking in those ways because they hadn’t been trained to, they weren’t aware. Boeing’s decision to keep the pilots in the dark and not to provide additional training to them was a key factor, I think, in why it was that the pilots made the errors that they did.

This is a human factor angle in all these accidents that you need to consider how will people react in these situations. If you had considered how will the pilots react in these crisis situations knowing nothing about it, it was quite predictable that they would and fail to do what they might have done had they been thinking about it in a simulator on the ground. Boeing had cut back on its human factor’s expertise. What it should have done in the design of this aircraft was ask itself seriously, how will pilots cope with this new situation? And run a series of experiments to see how will pilots cope with this new situation? They didn’t do that. And so that’s, I think one of the ways in which Boeing itself contributed to the pilot error.

The last thing I want to talk about here is the way of re-empowering the engineers, which is vital in this case and in all the other major accidents that I’ve studied. Ways need to be found to re-empower the engineers. It’s about organizational redesign. It’s about redesigning the structure of reporting, reporting lines so that engineers are not reporting to relatively low-level business managers. The reason why they mustn’t be reporting to low-level business managers is because the Those business managers, their primary concern is maximizing profit and production.

When they’re talking to their engineers, they will not be asking the question, Is this design good practice? Is this engineering good practice that you’re using in your design? But the question is, Is it good enough? Is it good enough? That’s a fundamentally different question because it’s inviting the engineers to cut as many corners as they possibly can, provided that what remains is good enough to ensure safety. That way of phrasing it, as you can understand, is going to over time corrupt the judgment of those engineers, especially as their bonuses are determined by these managers. These managers will be warding bonuses on the basis of how pliable and how compliant these engineers are with the needs of that business manager. Now, the only way around that is to stop, is to alter these lines of reporting and ensure that the working engineers don’t report in that way but report up to a more senior engineer who reports further up an engineering line, ultimately to a chief engineer who then reports to the CEO. Now, of course, engineers can’t operate entirely independently of commercial pressures. They have to be subordinated to the company at some point. If they’re subordinated at the point of the CEO, what that means is that their concerns will flow upwards freely to that very top of the company.

It’s the CEO who will be making those decisions and will be accountable for those decisions. As things stand, all those critical decisions are buried, and the CEO and top management never gets to hear the compromises that are being made. We have to find a way to ensure that the CEO, in a sense that his face, his or her face is rubbed in the facts of what is going on. They realize that the pressure on their engineers is to give them an answer that, okay, this is good enough. Once the responsibility is put on the shoulders of the CEO, you’re going to get a better outcome because they don’t want to be tolerating something which is not good enough. Sure. Yeah. Then, of course, the other feature of this is that that chief engineer also has a reporting line to the board, and that’s really important. The chief engineer will have dual reporting lines, one to the CEO, but he’s in a position to speak to the board independently of the CEO. If he or she thinks that the CEO is not passing on the relevant information to the board, then the chief engineer is in a position to do that.

These are some of the things that came out of that inquiry. This is one of the reasons I think that the Boeing case is such an important one to study because it dealt with these matters. It’s just something I think that boards operating in all major hazard industries need to be aware of the kinds of lessons which come out of this particular accident.

I think one of the pieces you bring up, you talk about the reporting lines of engineers. I would draw a parallel as well of reporting lines of safety functions in most organizations in that if it’s embedded inside the operational areas, you have a risk that the information remains there. They advise the same issues you talked about from an engineering standpoint may not percolate to the right levels of the organization. In the same way that you wouldn’t want audit to report to the lines of business.

Yes, that’s right. Auditors need to report to the top of the company. They need to find… It’s very interesting because audit firms are appointed by the company. If they provide a positive view of what the company is doing, they’re likely to be reappointed. That’s an unfortunate conflict of interest that they are often in. In far too many cases, auditors have failed to report things that are wrong because they’ve… Or at least the way they’ve expressed it has not raised alarm, and it’s deliberately designed not to raise alarm because they’re ultimately concerned about the next contract. That’s another conflict of interest. I think we have to be very aware of conflict of interest and design systems, design organizations, so that we don’t have those conflicts of interest. In the area of safety, that would mean that safety auditing auditors should not be appointed by the company. They should be appointed by… This is one possibility. They could be appointed by the regulator. You might have a pool of auditors available to the regulator, and the regulator would pull one of those out of the hat and say, okay, your job this year is to audit Boeing, if it has the relevant expertise.

That way, you’re removing that conflict because they have no more, no less chance of being appointed to Boeing next time around, regardless of the findings that they come up with. I think this is what I’ve seen in every single accident I’ve looked at, is that so many people are compromised in various ways. This is, I think, why boards need to be so alert to what can be going wrong, be asking questions all the time about what compromises is being made in the development of the information which we are seeing.

I think the same point I would make around when you talked about at Boeing, the need to have expertise specialists at the board level, in addition to a subcommittee, I would say it’s something as well, same in terms of operational expertise, expertise and safety. So, beyond the Boeing case study, it’s obviously around engineers and engineering safety. But in in a mining organization or in different other organizations, it may just be somebody who understands the context, the operational needs, and the safety elements and safety risks, some awareness of it, and potentially even value in having better awareness and training for board members around safety and what does it mean to have the right safety culture within an organization.

Yeah, I think this is right. I think each organization will be different. It’s a question of working out what is critical and then ensuring that you’ve got people on the board who understand the critical issues. They will be different. In health care, for example, this is another situation where these are in hospitals. This is another situation where It’s vital that people with expertise in what can go wrong are there in decision-making roles. I don’t know whether you know that there’s a very famous accident analyst by the name of Jim Reeson, and He’s done a lot of work on major accidents in the oil and gas sector. But in the last part of his life, he was working on the medical sector. Medical accidents, which involve accidents to patients who are in hospital for other reasons. Nevertheless, there are accidents which can cost the lives of these patients. The issues are very similar. It’s about identifying what’s going on, having people whose job it is to focus on what might be going wrong and learning from that.

One other thought that comes through is you talk a lot about shareholder value versus stakeholder value. The thing that strikes me, you mentioned BP as an example. We are obviously talking about Boeing. In both instances, short term shareholder value appears to be what was prioritized. But the long-term value of both BP and Boeing took an incredible dive following these incidents. Is there a need to really rethink what shareholder value means?

Yes. The story of share buybacks is a very important one here. You’re right that the rewards that go to the top company, the top managers in the company, are based upon annual performance. That means that everything is short term, and the long-term horizon disappears from their view for the most part. One of the, I suppose, most dramatic and most extraordinary examples of this is the phenomenon of the share buyback. This became popular, was made much easier than previously, and it became popular during the era of the Reagan residency in the 1980s. What share buybacks involved was… Well, you have to think of it in this way. Company makes a lot of money in one year. Big profit. What does it do with that big profit? Well, the new avenue which has opened up to them in the 1980s was to use that big pool of money for the company to buy shares, buy back shares on the stock market. Now, this is an extraordinary… It’s a puzzle, really, how this can happen. How can a company buy shares in itself? But that’s what’s going on. That’s what’s going on. The company uses a lot of this under the instruction of the board and the CEO, the company itself buys back a lot of shares in itself and then cancels them.

There are now fewer shares in this company. The total value of the company has remained unchanged, but there are fewer shareholders, which means that every share individually is worth more. After the share buyback process has been executed, the remaining shareholders are winners in this situation. Their share price, their share value has gone up, and therefore the top management, they’re winners. Their bonuses depend upon the share price going up, and this is what’s happened. And so, they’re reaping these massive rewards. And that’s fine for them. But what does it mean? It means that this money which had been earned by the company is being looted, as somebody said. It’s being looted by the shareholders, and it’s not being used in ways that will benefit the company itself. It’s not being used to do research and development. It’s not being used to develop new ideas, new aircraft in the case of Boeing. It means that the company can stagnate. This is what was happening to Boeing at the time. It was stagnating because it was resting on its laurels and redistributing all its profits in the way I’ve described. Now, the consequence of this was that Boeing was in a competition with Airbus, as everyone knows, and it was a very fierce competition.

At this time, around the year 2000, Airbus was marketing a new aircraft, which was a direct competitor with the 737, and it was recognized by many to be a much better deal than the existing 737, and Airbus was getting all the orders. Now, this was a crisis for Boeing, in fact, because I think it was American Airlines, which had previously bought only Boeing aircraft and a sense of loyalty to Boeing, placed a major order for Airbus aircraft. This was a crisis, as I say, for Boeing. It was a shock. They said, we need a new aircraft. It was too late at that point to be doing the R&D, the research and development for new aircraft. They said, well, we’ve got to do something. What we’ll do is simply put bigger and better engines on the existing design and go to market with those. Now, that was the design change which led to the 737 max. Because it was a shortcut and a spur of the moment decision to do this, they didn’t think through and didn’t have the time to think through what the consequences would be. This design change actually introduced this tendency to nose up that I spoke about before. But yeah, so Boeing was not in a position to develop a new aircraft which would compete effectively with Airbus. This really is one of the critical steps in the story as to why these defects went through to market.

Excellent. Andrew, thank you very much for joining me today. You’ve written numerous books on various events, the latest one published by CRC Press, Boeing: The 737 MAX Crisis and Aviation Safety. You talked about BP investigating multiple different at incidents, published multiple different articles, including some recent ones I was looking at on your LinkedIn profile, on risk matrices and so forth. What’s the best way for somebody to keep in touch, to learn more about some of your articles, your publications, and your books?

Well, I’m always available on email. My email is [email protected]. That stands for Australian National University, Au. Edu. Au. But I think the other thing is I’m also on LinkedIn, if you want to contact me on LinkedIn. The books are widely… If you know the name of the book that you want to access, it’s available in bookstores. Amazon has a lot of these books, and that’s a way to get in touch with me. But I do answer my emails, so please feel free to Contact me.

Excellent. Thank you so much.

ABOUT THE GUEST

Andrew Hopkins is Emeritus Professor of Sociology at the Australian National University, Canberra. Andrew was a consultant to the US Chemical Safety Board in its investigation of the BP Texas City Refinery disaster of 2005, and also for its investigation into the BP Gulf of Mexico oil spill of 2010. He was an expert witness at the Royal Commission into the 1998 Exxon gas plant explosion near Melbourne. He has written books about these accidents as well as books on mining disasters. Over 100,000 copies sold.

He has been involved in reviews of Work Health and Safety regulation and regulators and has done consultancy work for major companies in the mining, petroleum, chemical, and electrical industries, as well as for Defence. He speaks regularly to audiences around the world about the human and organisational causes of major accidents.

BSc and MA (Sociology) from Australian Natl U, PhD (Sociology) from U of Connecticut.
Independent member of the Air Force Board of Inquiry into the poisoning of F111 maintenance workers. Author of the Board’s report.
Winner of the 2008 European Process Safety Centre safety award, the first time it was awarded to someone outside Europe.
Honorary fellow of the Institution of Chemical Engineers in recognition of his “outstanding contributions to process safety and to the analysis of process safety related incidents”
Life member of the Aust Institute of Health & Safety. Recipient of an award for “lifetime achievement”
Officer of the Order of Australia (AO) in recognition of his “distinguished service to industrial safety and accident analysis”
Former member of the advisory board of NOPSEMA – the Aust Nat Offshore Petroleum Safety and Environmental Management Authority
Member of an expert panel that drafted the Global Industry Standard on Tailings Management.

Books by Andrew Hopkins:

Making Safety Work (Allen & Unwin, 1995)

Managing Major Hazards: The Moura Mine Disaster (Allen & Unwin, 1999)

Lessons from Longford: The Esso Gas Plant Explosion (CCH, 2000)

Lessons from Longford: The Trial. (CCH, 2002)

Safety, Culture and Risk (CCH, 2005)

Lessons from Gretley: Mindful Leadership and the Law, (CCH, 2007)

Learning from High Reliability Organisations (CCH, 2009). Edited

Failure to Learn: the BP Texas City Refinery Disaster (CCH, 2008)

Disastrous Decisions: Human and Organisational Causes of the Gulf of Mexico Blowout (CCH 2012)

Nightmare Pipeline Failures: Fantasy planning, black swans and integrity management. (CCH 2014) with Jan Hayes

Risky Rewards: The Effect of Company Bonuses on Safety (Ashgate, London, 2015) with Sarah Maslen

Quiet Outrage: The Way of a Sociologist (CCH: Sydney, 2016)

Organising for Safety: How Structure Creates Culture. (CCH, 2019) Credibility Crisis: Brumadinho and the Politics of Mining Industry Reform (CCH, 2021), with D.Kemp Sacrificing Safety: Lessons for Chief Executives (CCH Sydney, 2022) Boeing, the 737 MAX Crisis and Aviation Safety: The Perils of Profit-Driven Engineering (CRC, UK, 2025)

For more information: https://sociology.cass.anu.edu.au/people/professor-andrew-hopkins

Contact: [email protected]

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Looking Beyond Human Error to Improve Safety with Dr. Mark Young

Oct 3, 2024

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ABOUT THE EPISODE

We all make errors all the time. Join us for a fascinating conversation on looking beyond human error to improve safety, featuring special guest Dr. Mark Young. With profound insights into human factors and backed by solid research, Dr. Young shares the psychological mechanisms behind errors and emphasizes the importance of fostering a learning culture to enhance safety. The conversation also covers the impact of vehicle automation on safety and the critical role of fatigue risk management in safety-critical industries. Don’t miss this engaging episode!

READ THE EPISODE

Real leaders leave a legacy. They capture the hearts and minds of their teams. Their origin story puts the safety and well-being of their people first. Great companies ubiquitously have safe, yet productive operations. For those companies, safety is an investment, not a cost for the C-suite. It’s a real topic of daily focus. This is the Safety Guru with your host, Eric Michrowski, a globally recognized ops and safety guru, public speaker and author. Are you ready to leave a safety legacy? Your legacy success story begins now.

Hi, and welcome to the Safety Guru. Today, I’m very excited to have with me Professor Mark Young. He’s a human factor professional and a professor in transportation, University of South London, does a lot of work and research in this space. I’m very excited to have you with me, Mark. Tell me a little bit about your background and how you got started in this space.

Hi, Eric, and thanks so much for me on. It’s great to be here. Thank you for the introduction. I actually started out in psychology. My first degree was in a psychology department. As part of that, I started learning about cognitive psychology and how humans think and make decisions and perform and took a course in human factors during that time, which got me really interested in mixing my two interests of how people think and behave with technology stuff in the real world and how that applies to making the world better in terms of systems, interfaces, design of equipment, etc. I went on and did a PhD in that topic in the University of Southampton, using the driving simulator, looking at the impact of automation on driver mental workload and ultimately performance. The stuff that’s around now quite commonly in our car, so adaptive cruise controls, automatic steering, that thing. What that did in terms our attentional capacity, what that did in terms of mental overload. A lot of people have been concerned for a long time with things like overload, if you got too much to do and how that affects your performance, but there was less interest in the underload side of that equation, which can be just as bad for performance as overload.

That’s what I got interested in looking at using the simulator, looking at the effects of automation on drivers. I carried on in academia for some time, working at a partner in Southampton and then on to at Brunel University. Again, doing work in driver behavior, looking at things like eco-driving, looking at things like driver distractions from advertising, from meeting and drinking, that thing. And the more I got interested in I’ve got a performance in particularly safety critical systems, and I got interested in accidents, an accident investigation. Then an opportunity came up to work with the UK’s rail accident investigation branch. This is a bit like the NTSB in the States. They do independent investigations of accidents to improve safety. I’d like a job there and I was very fortunate to get it. I worked there for 11 years, which flew by. A very satisfactory time I had there working on a number of investigations across different areas of the railway, learned an awful lot about railway operations and applied my human factors experience to understanding what’s gone wrong in these accidents and how we can make recommendations to improve safety in the future. Although it sounds on the face of it a bit of a grim job, and it certainly had its moments, it was incredibly satisfying and was a great place to work.

But then about a year and a half ago, the opportunity came up to return to academia. In fact, to my original university back at Southampton with this role as professor of Human Factors in Transport within the Transportation Research Group. It was too good an opportunity to pass up, really. I went for that and again, was very fortunate to get it and have been back here now for about a year teaching and researching within… I’m actually in a School of Engineering, Department of Civil Engineering, even though I’m not an engineer. As I said, my original background was in psychology. But because human factors really breach all those disciplines. It’s a very interdisciplinary topic across engineering, design, psychology, behavior, all those things. It’s a very applicable place to be, and we’ve got great facilities here. Again, a much-upgraded simulator compared to the one I was using 25 years ago from PhD and interested in the vehicle and bicycle and that stuff. So great opportunities to carry on doing research in that area.

We’ll talk shortly on the impact of automated transport on safety. But maybe First, let’s start on the human error side because we start most investigations looking at a degree of human error. Tell me a little bit about some of those elements and some of the work you did on the transport side.

Yeah, absolutely. It’s long been a bit of a bug bearer of mine, actually, that when you quite often see in popular media and reports when an accident happens, that so-called human error was to blame. Every time I see that, and it happens quite a lot, it always gets up my back a little bit, partly because obviously, looking at this area, you know quite a lot about it. But the reason being that, well, there’s a couple of things associated with that, really. You quite often see statistics that anything up to 80 or 90% of accidents are due to this notional human error. I take issue with that, partly because from my point of view, well, okay, you’re talking about the last person who touched it when you talk about those statistics, you’re talking about the driver, the signaler, the pilot, whoever that might be. That’s who people are typically referring to when they talk about this 80, 90% figure. From my point of view, I think about human factors from a socio-technical systems perspective. It’s not frontline performance. Yes, that’s an important part of it, and we absolutely do look at that. But in the accident investigations and with this socio-technical systems perspective, we dig beneath that.

We have to understand what led that person to make those decisions and actions at that point in time in that place. And there’s a whole bunch of stuff that can lead up to that from their training, from the systems they’re using, the equipment, the interfaces they’re faced with, the processes and procedures, right the way up to the culture of the organization, the regulatory framework. You can even take it up to government and national levels if you wanted to. So, there’s a whole bunch of other stuff that goes behind that so-called human error figure. Actually, when you think about it from that point of view, there are humans involved at every single step of this chain. Even what might be a technical failure, a wheel bearing that’s failed and caused a derailment or something like that, well, ultimately, why has that failed? Is it a design issue? Was there something wrong with something missed in maintenance, something like that? There are actually humans involved every step in this process. So, from that point of view, you could argue human error is a factor in 100% of accidents. So that’s one reason I have issue with that.

Fair? Yes. The other reason is this whole thing that as we’ve just discussed, it really is just the starting point. It puts the blame on the frontline operator. And like I was just saying, there’s so much more stuff behind that. So yes, if you go and investigate an accident, your starting point is what happened on the front line. How did we get to this point in time? And you will interview those people involved. You will try to understand what they were doing at that time. But then you dig so much further, you dig much more beneath that. That human error is just the starting point, and we dig beneath that. When we’re making recommendations, which is the end product of an investigation, we want to make stuff better. We want to improve safety in the future, make recommendations to plug those gaps that may have emerged in that system and stop this thing happening in the future. We make those recommendations so much further upstream. There’s no point making a recommendation saying, retrain this person or do something about what they were doing on that. Because all that’s doing is putting a sticking plaster on it.

All that’s doing is saying, we have fixed that one person’s activities at that specific location at that specific time. Sure. Another person could step into those shoes and do exactly the same thing on another day slightly different circumstances. If we go much further up the stream into the socio-technical system and make recommendations at a much higher level, we can stem that tide. If you think about it like the source of a river and loads of tributaries or something like that. If we stem the source, we can affect so much more, we can have much bigger impact to all those other people that might step into those shoes on that front line.

I think this is key because it’s one of the areas where transportation, I think, has gone much further, is in most other industries, it’s blamed the employee. It’s focused on the error, the person that made the mistake, as opposed to acknowledging that as humans, we all make mistakes, and none of us have not made a mistake in the last, probably hour or short period of time. We’re not fixing things. That’s, I think, the area where in aviation, but in transportation in general, there’s been the biggest shift is really understanding, recognizing that there’s a lot more to the chain, that if we want to fix it, if we want to prevent In an incident, we need to go much deeper.

100 %. And what you’ve just described there is exactly what I teach my students. We all make errors all the time. It’s all about the context in which these errors occur. So everyday errors and the psychological mechanisms behind our everyday errors are exactly the same, whether we are at home doing something quite inconsequential or on the flight deck of a of a major eyeliner. There’s a really good example, and it’s a fundamental error type that we all make, and it’s a mode error. And a really simple example of this is using a digital alarm clock and you’re trying to set the alarm, but it’s actually in time mode and you’re resetting the time on it instead. So, it’s an action that might be appropriate in one mode and you are unknowingly in a different mode and that becomes, by definition, an error. Sure. There have been examples of major airline disasters where these basic mode errors, like setting a particular altitude mode, descent mode, which the same numbers on the flight deck can relate to flight path angle or rate of descent. And one, if you put the same numbers in, it can be a much steeper descent in one mode than another.

And that has, in the past, led to a major disaster. So, it’s exactly the same error type, but in the context of a safety critical system, it can lead to much greater consequences. So, you’re absolutely right. We shouldn’t just be thinking about the last person who touched it. And a lot of that, I got to be honest, is, and I’m not going to go into specific details, but some of that does come down to even geographical different cultures. You see certain cultures that are very, very quick and ready to pin blame, and even legally, even be charging people involved on the front line before any proper investigation has taken place.

That also limits our ability to learn because now it’s immediately going to default, and people are going to start hiding some of the key facts.

100% indeed, yeah. These safety investigations are all about safety learning. The organization I used to work for and the NTSB and other similar organizations around the world, they’re all about safety learning. They It’s not going to go out for blame or liability or prosecution or anything like that. It’s got to be about safety learning. You’re absolutely right. If people believe that they are personally going to be at risk, they’re not going to share all of the facts. A really big part of that safety investigation is ensuring you get that trust in these people and ensure that you are getting all of the facts and on all of the learning so you can make those appropriate recommendations.

One topic we were also discussing initially is around fatigue and how fatigue plays out in often is a precursor of error, as we all, when we’re fatigued, are bound to make mistakes. Tell me a little bit more about fatigue and how different industries look at it.

Yeah, it’s a really good example of what we might call a performance-shaping factor. So, something that can affect us all, and as you just rightly said, affects our performance to a greater or lesser degree, depending on how fatigued we are. And the nature of transportation systems today, whether that be rail, aviation, whatever, 24/7 industries, they’re all going to be subject to fatigue to a certain extent because we are animals, we are human beings, we are animals, and we are circadian animals. We are designed to be up in a day and a sleep at night. If we mess with that in any way, trying to get people to work at night and sleep in the day, there’s always going to be an element of fatigue risk. You can never completely eliminate fatigue with a shiftwork-type industry, but you can do stuff to manage the risk of that fatigue, then translating into performance difficulties. Because if we’re fatigued, it can affect our reaction times, it can affect our decision making, it can affect our mood, and it can even have long term effects on our health, gut problems, heart problems, that thing, if we have chronic fatigue over a length of time.

It’s really important that we do manage this risk. And an aviation rail over the years have made great strides in trying to not just understand the causes and consequences of fatigue but put in place what they call fatigue risk management systems to try and mitigate the risks of that. And that’s not just about managing the hours of work. Yes, absolutely. Managing the shifts is a big part of managing fatigue, so not working too long, making sure people have got sufficient rest in between shifts. But it’s also got a qualitative angle. It includes things like fatigue reporting. Just as we were just talking about in terms of gaining trust from people in an investigation to report what’s happened so we can get the safety learning, it’s the same thing with fatigue. If people are tired for whatever reason, employers, managers would need to know about that. We don’t really want people in the cab of a train or the flight deck of an aircraft doing their job if they are fatigued. It’s really important to understand that and understand where that fatigue has come from so that we can then do something about it, because a lot of it is just about sleep and sleep opportunities.

The reason we talk a lot about managing work hours is because that’s the bit that organizations have control over. But really what they’re doing with that is providing people the opportunity for rest. It’s about making sure people have got adequate opportunity for sleep when they can regenerate and restore their abilities to come back fit for work the next day. The fit for work thing is, by the way, not just fit for work at the start of their shift, but all the way through to the end of it as well. Some of the accidents I was involved with in my previous post, we’ve seen accidents happen towards the end of a long night shift. People might have been turning up for work, fit for work. They do a fit for work check when they book on, and they might be fine then. But what are they going to be like 10, 11, 12 hours later? And that’s when you see these incidents tend to occur. So, it’s by no means solved. There’s a long way to go, and it’s the thing, as I say, you’re We’re going to completely eliminate fatigue in a shift work industry, but we can do a lot to manage and mitigate the risks associated with it.

Are there some learnings from what’s being done in the transportation space that could be carried into other industries around the fatigue management side of the equation? Because obviously, shift work is a key component, and how you manage the shift and the hours of rust and so forth, but other things that could be brought forward to other industries.

Definitely. As I say, aviation, rail have gone great strides over the years to advance their fatigues management systems. Marine, to some extent, I guess, because of the nature of marine work, maybe hasn’t quite come as far as the other transportation modes, but they are starting to work on that. But one area where it’s really important, and this is an area that I’m getting into myself at the university, is healthcare. So, fatigue management in healthcare hasn’t really, certainly, I’m speaking for the UK now, hasn’t really gotten hold of this issue at all. I I wear another hat with my professional institute, the Chartered Institute of Ergonomics and Human Factors. I’m current President of the institute, and we published a white paper just a few months ago, actually, part of a… I don’t take full credit. It was part of a group effort but the white paper was on fatigue risk management in health care. Taking these lessons from other industries, primarily transport, and trying to apply those in the health care context. Because as you can imagine, some of these long and complex surgeries can go on for hours and hours and hours. There’s been, historically, this culture of powering through consultants and surgeons not feeling that they are susceptible to these issues.

But we’re all human at the end of the day. It doesn’t matter whether you’re a pilot, a driver, a train driver, or a surgeon. We all are subject to the whims of this circadian rhythm, this daily diurnal rhythm that we’re all susceptible to. It’s really important that we try and manage that and bring those lessons across. I’ve actually got a PhD student starting next month, actually, doing a project on this very topic, trying to understand fatigue in health care and how we can manage that.

It’s also an industry that has shifts that go through the night, particularly on the nursing, but the doctors, maybe not operations through the night, although there could be in emergencies, but high impacts.

Yeah, and look, that’s right. But the thing is, there are errors in health care, and there are consequences from that, but they are not on an individual level. They’re not on the same scale as a major airline disaster. But it’s a bit like road accidents, really. So, accidents tend to happen frequently, but a few people will be injured or killed on each individual occasion. So, they don’t tend to gain the public attention or hit the news in the same way as an airline going down with a couple of hundred people on it. So that would be very newsworthy. But actually, when you look at the data, that thing is happening regularly on the roads and in healthcare, just in ones or twos. It’s really important that we do get hold of these issues.

The last piece I really want to touch on is your work and your research around automated transport because there’s more and more instances of this automated transport, different vehicles. You talked about the cruise control and the adaptive cruise control. But we’re moving more and more towards vehicles that have high levels of automation, which for the most part should improve safety, but also introduces a lot of new risks. Tell me a little bit about the work you’ve done in this space.

Yeah, that’s right. It’s really interesting because as I mentioned at the top, this stuff I was doing 20, 25 years ago is almost more relevant now than ever. So, these systems are now live. They’re in our cars where many of us have probably experienced them and are using them. And the point we’re at now in terms of technology progression and legislative progression, too, and certainly I know a few states in the US, and we’re going to be doing that in the UK quite soon, is moving forward to this what they call Level 3 automation. I won’t go into detail about the different levels, but up till now, we’ve had bits of the driving task automated for us. You can automate speed with cruise control and adaptive cruise control. You can have some steering automation with lane keeping support and that thing. But we’re getting to a point now where we can automate an entire part of the driving task, but only in certain circumstances. So, you can actually technologically and legally take your attention away from the road, but only in a given context. So that might be on a highway under certain traffic conditions, that thing.

And you need to be ready to step in when the system needs you to. So, part of this whole thing will be the system monitoring the driver as well, understanding from things like eye movements and other behaviors, whether or not it thinks that you’re attentive and what they call fullback ready. You need to be ready to step in as a fallback user if the automation suddenly goes out of its design scope or some other technical issue. For me, from a human factor’s perspective, this is the really tricky phase. This is the troublesome adolescence, if you like, of automation going forward, because what we’re saying to people, drivers, not drivers, but the people behind the wheel, is that, yes, you We switch off now, but we need you to be able to step in. There’s a whole bunch of questions that are still… There’s still research going on in terms of how quickly people can step in. What warnings do they need? How do we ensure they maintain their attention that they are ready to step in? Because you can’t just say to people, Okay, you can sit there and watch a movie or do your emails or whatever, but as soon as I ring this bell, you need to be back in and driving.

People don’t work like that. We need to regain our situation awareness. We need to think, Okay, what’s going on? What are you telling me? What is the automation doing? What’s going on all around me now? How am I supposed to get back into the loop on this thing? What you said about the automation introducing all sorts of new problems, that’s absolutely true. We’ve seen that in aviation, too. We learned a lot of lessons from automation and aviation in terms of translating that across to automotive. Because yes, okay, fundamentally, there probably will be fewer accidents on the main with automation than with human drivers. I think the jury is still out on that to some extent. But I think it’s probably fair to say that that will be true. But what we will get is a whole bunch of new categories of incidents and accidents, because what that involves now is not just being aware of the driving task and what’s around you, but also managing this relationship with the system. You’ve got another layer, if you like, of a driving task there. What’s this system doing? How do I know what it’s coping with? What do I need to do?

It becomes an issue of communication. It’s almost like driving with a co- driver, a human co- driver, and that analogy has been drawn. This system now is becoming part of a team. Human automation teaming is a real big area of research at the moment. How do we actually work together? How do we communicate and coordinate our actions for the ultimate good of the system performance. We want to be able to get from A to B safely and as efficiently as we possibly can, and we need to work together to do that. We can learn lessons from human teamwork. How would I work with another human co- driver? We’d be talking to each other all the time. We’d be saying, Okay, there’s something weird going on here. I need your help here to cope with this. The thing is with automated systems, they tend not to communicate like that, and we need to get better at that. We need to be able to design these systems to work better with their human counterparts. And that’s a two-way thing. We need to work so that the humans can talk to the automation and the automation can talk to the humans.

Otherwise, I think we will see a whole bunch of new problems going forward. And that causes all sorts of sticky legislative and ethical and moral issues because, okay, society, I’m not saying this is right, but society might well accept people crashing or having incidents on their own back. But now what’s happening is, well, who’s now responsible? This system has maybe caused this accident. So, who’s responsible for that? Is it the driver for not paying attention? Is it the manufacturer of the vehicle or the provider of the automated system? Where does that responsibility now lie? And these are all questions that are still open for debate.

And we’ve certainly seen, you brought up aviation. We’ve certainly seen in aviation, a lot of incidents where the autopilot kicks off and there’s a warning that comes in. The amount of time for the pilots who are highly trained to really recognize what’s happened, in some cases, like the 737 max, where systems kicked in automatically because they interpreted data in a way that they shouldn’t have. The pilots weren’t even able to overcome and take over control of the flight.

That’s right, because they weren’t aware of what was going on with the system. There’s a whole bunch of stuff behind that. 737 is one of these incidents that really illustrates this system’s view, because there were all sorts of even organizational stuff going on there about not providing the flight crew with appropriate training and understanding of what that system should be doing. But, yeah, fundamentally, it came down to communication. The system actually informing the flight crew about what’s going on, what they need them to do, and that communication breakdown. It’s the same thing with the Air France 447 accident. Same thing happened there. Workload comes into play again with that one. It’s in the cruise phase of flight over the Atlantic, very low workload phase. Then the system started getting screwy readings from the Pepto tube for the airspeed. Then it’s I’ll cut long story short and oversimplifying, it got to a point where it basically said, I can’t cope with this anymore. I need you to take over, and gave this back to the flight crew, at which point the flight crew go, Wait, what’s going on here? Because they’d never seen that situation before.

They’re highly trained. Nothing wrong with their training or what they did. It has been said in research that these kinds of situations, again, coming back to that point about human error, you could very easily say, well, it was the pilot’s fault because they should have taken over flying. But no, there’s an alternative perspective on this where actually the pilots just weren’t able to save the situation. It wasn’t the pilots that caused it, they just weren’t able to save it because actually what happened was, they were faced with a situation that was a surprise to them, a fundamental surprise. I’m not just talking like a birthday surprise. This was something that they were completely unprepared for and not expecting in the slightest and were unable to cope in that particular situation, unable to diagnose and resolve the situation in the limited time they had available to them. You can’t really put that on the flight crew. It is a socio-technical systems issue.

You’re also dealing with an industry where the level of training is significantly higher than the typical driver.

Wow, yeah, seriously.

Then the driver does doesn’t have the simulations, all the various training components that happen every year, and suddenly they have to deal with the technology in front of them.

That is so true. Some people say, well, aviation must be more complicated because you’re moving in three dimensions and all of that. But no, there’s a prevailing perspective that no, driving is way more complicated because it’s so much more random. You’ve got all sorts of stuff that could… Okay, it’s only in two dimensions, but you get all sorts of stuff that could happen. These rogue other road users, you don’t know what other drivers are going to be doing. What’s that pedestrian going to do? Is that cyclist going to ride out in front of me? And again, another point about this intermediary space until we get to full automation at some point in the future, probably decades away, to be fair. But it’s not just about this intermediate automation inside one vehicle. We’re going to have a mixed fleet on the road. We’re going to have some cars that are human-driven, some cars that are partially automated. How are they all going to interact with each other? How are they going to interact with other road users, pedestrian cyclists, vulnerable road users? And that thing? Actually, I wrote a book and a paper on this myself last year with a slightly contentious perspective on it, but deliberately provocative, suggesting that You know what?

We should just wait. We should just wait until we are ready to fully automate and then jump off that cliff and just say, Right, okay, we’ll hold back, let people drive their cars up. Yes, we can use the technology to help them. Yes, we can provide safety systems, the stuff that we’ve already got, like antelope, braking systems, traction control roll systems, collision, the stuff that’s like a safety net for drivers. For sure, use those systems to help people do what they normally do. But until we can fully and completely automate the entire task, and I can just get in my car on the driveway here and it can take me to my office or wherever I need to go without any intervention from me, then maybe we need to think again about that relationship with the automation.

Yeah, I think provocative Statement, but I think there’s a lot of merit in it in that if you look at aviation, there’s so much more training, so much more guardrails around dealing with the automation. And yes, we talked about the Air France, and the Boeing 737 max, both illustrations were technology and humans were trying to figure out how to interact with each other.

Yeah, that’s right, indeed. And as you rightly point out, drivers on the road get barely any training in comparison. And That’s another question. Will we need to train people to use the automation? Again, using the UK as an example, we have a different level of driving license for using automatic transmission, automatic Gearbox in our cars. If you train and pass a test on an automatic transmission, you can’t use a manual or stick shift until you’ve taken another test. Will we need to think about that for more levels of automation in our vehicles? Is that something that we need to be able to manage the system as well as driving the car? But yeah, I’ve always said that driver training really just tells you how to operate the car. It doesn’t really tell you how to drive properly. It’s a lot more stuff going on there. As you say, in comparison to what flight crew gets, it’s a world apart. Yeah.

Mark, thank you very much for joining me today. A fascinating topic. I think the main takeaway for industries in general is really to think about how I can bring some of these topics from the transportation space. We talked about fatigue, but also, we talked on just the element that humans are going to make mistakes. We are bound to make errors. How do we create a system that reduces the consequences as opposed to blaming the individual at the end? Thank you so much for joining me today.

Thank you for having me. It’s a pleasure.

ABOUT THE GUEST

Professor Mark Young is a professor of human factors in transport within the Transportation Research Group at the University of Southampton and is currently the president of the Chartered Institute of Ergonomics and Human Factors (CIEHF). Mark has nearly 30 years’ experience working in human factors across transport modes in both academia and industry. Before joining the University of Southampton in June 2023, Mark spent 11 years working as an Inspector at the Rail Accident Investigation Branch, applying his human factors expertise to the investigation of railway incidents and accidents. Mark has written over 70 peer-reviewed journal papers and five books, he is a Chartered Ergonomist and a Fellow of the CIEHF.

For more information: https://www.southampton.ac.uk/people/62gmgv/professor-mark-young

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After the Crash: Miracle Survivor’s Mission for Change with Mercedes Ramirez Johnson

Sep 5, 2024

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ABOUT THE EPISODE

We invite you to join us for this compelling episode as we explore the incredible journey of Mercedes Ramirez Johnson, a miracle survivor of the 1995 airplane crash that tragically took 160 lives, including those of her parents. Tune in as Mercedes recounts her miraculous story, the critical safety issues uncovered in the aftermath, and the lessons learned from this tragedy. Listen in as she transforms her personal tribulation into a mission for change, striving to prevent future aviation disasters and ensuring no one else endures what she has been through.

READ THE EPISODE

Real leaders leave a legacy. They capture the hearts and minds of their teams. Their origin story puts the safety and well-being of their people first. Great companies ubiquitously have safe, yet productive operations. For those companies, safety is an investment, not a cost for the C-suite. It’s a real topic of daily focus. This is the Safety Guru with your host, Eric Michrowski, a globally recognized ops and safety guru, public speaker and author. Are you ready to leave a safety legacy? Your legacy success story begins now.

Hi, and welcome to the Safety Guru. Today, I’m very excited to have with me, Mercedes Ramirez Johnson. She’s a safety and Leadership Consultant but has an incredibly powerful story to share about her experience as a passenger on American 965. First and foremost, welcome to the show. Really excited to have you joining me today and blessed that you were able to walk away from that flight. Why don’t we start with a little bit of your personal story and that flight, American 965, what happened back in the 1990s?

First off, Eric, thank you so much for having me as a guest on your podcast. It’s a big honor to be here. And one thing that I can definitely say is the experiences that I’ve been through, hopefully, can help other people through their life and professional struggles that they endure. So, yeah, my story begins on December 20th, 1995. It happened to me be my 21st birthday. So, my parents and I were on our way to Cali, Colombia, to spend Christmas and New Year’s and celebrate my birthday. It was going to be the trip of a lifetime that they had been planning for years. And We lived in Kansas City, Missouri at the time, and so flying to Colombia was going to be pretty much a full day affair, but we were excited to be able to spend the holidays with our aunts and uncles and cousins and everybody. This was going to be the first time since my parents had left their homeland that they were going to be back for the Christmas holidays. It was really special for all of us, including all the passengers of American Flight 965. Most of the people on that flight were families who were just returning to go home for the holidays.

So, it was a very festive, happy atmosphere on that day.

I saw the review of the whole story of what happened. Definitely, it was a holiday moment. I heard the stories of people waiting to look at the beautiful lights for the holidays on approach. Tell me what happened, because this is a stunning series of events, a new airplane at the time, one of the most modern aircraft that existed, the 757. Nothing wrong with the flight itself, nothing wrong with the airplane itself, and yet on approach, everything went wrong.

Yes. As passengers, the vast majority of the flight was perfectly normal. My father at the time worked for another airline so we used to be able to fly for free on other airlines. So, my family and I were very comfortable with flying. If there was ever a little bit of turbulence, it was never something of concern to us because we used to fly so much. And as a passenger, I remember I took a nap on my father’s shoulder, and when I woke up, I woke up feeling a little bit of turbulence, but nothing out of control. It felt like we were flying through clouds. So, I wasn’t afraid. I wasn’t scared. And I thought, oh, that interrupted a perfectly good nap. Let me fall back asleep again. And as I was trying to close my eyes and fall back asleep again, that normal little bouncing through the cloud’s feeling turned into just an abrupt situation where we, as passengers, just felt that the pilot took the nose of that plane and just pulled it straight up into the air, where one moment we’re flying regularly, horizontally across the sky, and the next moment, panic just erupts because we just feel that we’re just barreling into the sky like we were on a rocket ship or something.

As you can imagine, as passengers, we’re not hearing any announcements as to why we’re flying straight up into the sky. We don’t know why this is happening. Of course. But we just… Just pandemonic. People, men, women, children, everyone screaming and crying and panicking because we’re not aviation experts, but as a passenger, you know when something feels wrong, and we knew something was terribly wrong at that moment. It was probably a matter of 10 to 15 seconds where we’re flying straight up into the air. I remember hearing all these screeching, grinding sounds on both sides of the wings as we were heading up into the air. I And my instinct was just to grab my father’s hand and close my eyes. When I was little, I was used to close my eyes when I was scared. So even though it was my 21st birthday, I went into a little girl mode because I thought, oh, my gosh, this is just terrifying. And so, I grabbed my dad’s hand, closed my eyes, and I was just focusing on my mom’s voice in the row in front of me because she was praying out loud. And so, I was trying to ignore all the screaming and the crying of everybody else around me.

And I was just trying to focus on her voice and focus on calming myself down by just listening to her. And my last memory was just hearing this loud, crashing, booming sound that came from behind me. And at that time, I didn’t realize what that sound was. I just remember how scary it sounded because not only did I hear it, I felt it. And I didn’t realize at that moment that that loud, booming sound was actually our plane hitting the side of a mountain, making contact with a mountain. We weren’t supposed to land on a mountain.

No, you’re not. Nowhere near a mountain.

It was fatal contact at that moment. After that, I just blacked out, and I don’t remember anything until I woke up in the wreckage the next morning. It was something that during those last 10 to 15 seconds, we all knew something was wrong, but never did I think, oh, my gosh, we’re going to crash. Oh, my gosh, we’re going to die. I kept on thinking, okay, just fix it. Just straight. I remember under my breath, I kept on saying, just straighten it out. Just straighten it out. Just thinking, okay, if the pilot’s accidentally hit a button, just straighten this thing out. It can’t be that hard. I’ve been on a million flights. Just straighten it out. I guess that’s the eternal optimist in me, but I never actually thought, oh, my gosh, we’re to die. I just kept on thinking, just fix this. Just straighten it out.

You were literally feats away from probably having been able to straighten out if everything else had been done right. Although from what I gather, it wasn’t confirmed, but you weren’t necessarily that far away from that point. What if you share maybe some of the themes from the investigation? Because this one is a mind boggling one. When I was reviewing the incident, the series of mistakes, one after the other, things that should never happen on an airplane happened.

Right. I remember when I was still in the ICU, our family’s attorney I was in the ICU for nearly three months, recovering from all the injuries that I sustained from this crash. I was dealing with the grief of losing my parents because both my mom and my dad both instantly died upon impact of the plane hitting that mountain.

So sorry to hear that.

So aside from dealing with the grief of all that, I remember my parents’ attorney said, well, our main goal is for you to get better, but we’re going to be in talks with other passengers because there may be a lawsuit. And I thought, A lawsuit? It was an It’s nobody’s fault. It was an accident. As I was sitting there with five million different IVs in my neck and in my arms, and I wasn’t even thinking this lawsuit. Who thinks about these things when you’re in the middle of grief. But as the investigation unfolded, and of course, those things take years for the FAA and the NTSB to make their definitive conclusion decisions as to what caused the plane. But very early on, it was pretty evident that it was pilot error. It was human error. First, there was theories that the cartels had shot us down and that it was an on-purpose thing. All kinds of theories were running around in the hearts and the minds of different people. But once it became clear that it was indeed pilot error, it was very angering as someone who I’m just fortunate enough to have been able to survive it.

But for someone who lost their loved ones, my parents, I thought, oh, my gosh, this so easily could have been avoided. And not only that, but just even the pilots themselves lost their lives so needlessly, so uselessly. That’s where that bitterness really kicked in, because it was just a series of mistakes and oversights and omissions of things that should have been done, and verifications that should have been made, and navigational procedural steps that should have been taken that just did not happen. It didn’t happen because it wasn’t an issue because these were two brand new pilots. It didn’t happen because- No, 13,000 hours for the captain of flying. Especially, they are US-based. Different countries have different If you have pilots that are trained in other countries, the number of hours that they have to pass to become a pilot, you’re probably in the safest hands by flying with an American-based pilot. I don’t mean American Airlines, just a pilot in the US, the hundreds, if not thousands of hours that they have to prove in order to get their license. We were in the best hands. To my dying day, I will say that we were in the best hands.

These were two good men that just happened to have a really bad, bad day at work that day. It wasn’t because they intentionally crashed it, but it was really because of their lack of intention, their lack of mindfulness that just allowed this series of needless mistakes to happen.

There are some classic pieces that came out. We’ll go through some of the elements from the investigation. But there’s some classic elements where flight was delayed, there’s compounding issues where production pressure, this desire to arrive on time is an issue that happens in every industry. I would say aviation is one of the ones where they’ve done the best to manage it. But there’s still this desire to say, I need to land. There’s lots of references in the flight recording about the turnaround time, the rest time, and it’s right before the holidays. You’ve got multiple things that are creating an internal pressure. Tell me about some of the other elements that came out of the investigation because it’s, like you said, qualified, qualified people, lots of training, lots of oversight. Lots of phenomenal practices are in place, and yet simple mistakes that should have never happened occurred.

Right. I think I would say that the biggest mistake that caused this cascade of other mistakes was the fact that the pilots just entered in the wrong alphanumeric code into the navigational system. Not only did they enter in the wrong code, but then they didn’t cross verify to make sure, hey, did we enter in the wrong code? And so, everything they did from that point forward, they were making assumptions that they were headed in the right direction. But unfortunately, neither the captain nor the co-captain ever actually looked down to the navigational system to actually verify what coordinates had been entered. And neither the captain nor the co-captain ever looked down at the flight screen that would show them that we practically did a U-turn in the air, in mountainous terrain at night as our elevation is… We’re getting closer- Below the mountain range. Yeah, we’re getting closer to the ground because we were only about, I would say, 15, 20 minutes from landing. So, the landing gear sequence had already begun because as you get closer to the airport, you start slowing down and you start lowering your elevation. And so, they were basically flying at night with blindfolds on.

And air traffic control kept on asking them to verify when they make it to certain waypoints. And instead of actually looking at the navigational system to actually answer those questions, they just kept on powering through. I don’t want to go as far as to say that they were ignoring air traffic controls questions, but they definitely weren’t answering them in a truthful like, okay, this is exactly where we missed that waypoint, but this is where we are now because they had no idea where they were. It’s evident in the recording. Only once in my life have, I actually put on my headphones and listened to the Blackbox recording. But just with talking with you a little bit earlier, I think I might listen to it again because I haven’t listened to it since 1996, so many moons ago. But when the only reason they knew something was wrong was because that ground proximity warning alarm started to go off in the cockpit. It came up. Yeah, and that alarm tells a pilot that you’re coming in hot. You’re basically coming in too close to the ground at too fast of a speed and you need to pull up.

As you’re listening to this black box recording, you can hear the automated robotic voice telling the pilots to pull up. As this alarm is going off, they are telling each back and forth, Why the bleep is this thing going off? Where the bleep are we? What the bleep is going on? Because that’s when they finally looked at their instrumentation and realized, Holy crap, we’ve gone off- Nowhere nearby. Yeah, we’ve gone off like 130 miles in the wrong direction. And that’s what somehow, we missed the first mountain range because our elevation was still slightly higher, but we ran out of luck once we hit the other, literally hit the other mountain range. And it wasn’t until that alarm went off that they had any idea that anything was wrong.

When you look at that or we listened to the flight recording, because I had a chance to review it just before we spoke, complete situational awareness was completely lost. There’s a where they turned. The one you should be aware because as you said, you at night, you’re in between two valleys, in between three mountain ranges, essentially. They somehow ended up, instead of being in the mountain range, they should be in the valley, they should be, and they were in the one right next to it. Because they had turned 180 degrees, almost, sorry, 90 degrees to the left, almost, with the wrong instructions, which you would have felt the plane turn, rather than say, okay, are we in the right place? They continue and I essentially assumed that they had a direct landing. Now, the contributing factor is that I was listening to the radar for the ground was disabled, so it wasn’t working, so the airport had no visibility to where they were. There seems to be some signs where air traffic control was confused as to what they were hearing, but everybody had lost situational awareness based on at least the recording and some of the readings I had.

Right. Unfortunately, the cartels in retaliation to the government had destroyed a lot of those different radar towers leading to the airport. And so, communication between air traffic control and the pilots on approach to Cali, Colombia was always very, very pivotal, very important, because basically air traffic control is blind, and the pilots are relatively blind. They must rely on their instrumentation. But unfortunately for this flight, they chose not to. And so when it all boils down to it, after, I think it was about a five or six year investigation that the FAA conducted with the NTSB, both organizations ruled that for whatever reason, these pilots disregarded or just forgot or just did not complete 64% of the standard operating procedures from the time they pulled out of the gate in Miami until the moment we hit the side of that mountain. That doesn’t even include all the things that should have happened upon descent and approach and landing and taxiing and pulling to the gate. That doesn’t even include all the stuff that didn’t happen because we just didn’t make it to that point. Just from leaving Miami to the time we hit that mountain, for whatever reason, they only ended up doing 36% of all the standard checklists and verifications that they were supposed to have done.

If you think on any given day when anyone’s job is safety-focused, can you imagine going out in the field or going out on the line and only doing 36% of what you’re supposed to do? I mean, it seems insane. But these pilots weren’t insane. They just weren’t paying attention. Unfortunately for us, out here in the real world, we’re all guilty of losing situational awareness. We’re all guilty of mind wandering, where you could be in the middle of a task, but you’re thinking about the game that you watched last night, or you’re thinking about the last thing that your kids said as they were storming out the house on their way to school that morning. Our minds wander so much- Absolutely. That it’s up to us to get ourselves back to maintain that situational awareness, especially when our own health and safety and the health and safety of people around us is on the line. I think sometimes we can get so well experienced and so good at our jobs that we sometimes forget how tremendous of an impact our actions, or our inactions have.

I think this is the part is This is in an industry where there is very clear understanding that it’s very unforgiving environment to be operating in. This is the industry that has done the most from a safety standpoint, because if you look at there’s still somebody in America that dies, I think it’s every 96 minutes in a workplace injury. But if you look at aviation, it’s come a long way since the ’60s in a fairly nascent industry with only, I think, three fatalities on US oil in the last 15 years. So significant improvement. But you’ve got rigor, you’ve got consistency, you’ve got standard operating procedures, you’ve got checklist, it’s trained, it’s retrained and validated, and yet you can have drift. Exactly.

Yes. And the pilots are evaluated for their health and their vision and mandatory age requirements. I mean, there’s so many things that are worked in to try to keep this as safe as possible, that it’s almost like you almost have to go out of your way to not be safe in that environment. And we’ll never, sadly, we’ll never be able to get into the minds of these pilots as to why they inadvertently allowed this to happen. But as ugly as it sounds, they did allow this situation to escalate beyond control.

I think the flip is also, to your As I said before, we all do these things. We all do careless things. This is the environment where there is a lot of constraints, checks, balances to make sure this doesn’t happen. But then when you say 64% was disregarded, in my mind, I’m thinking, this could happen anywhere else. In some cases, even if I think about utility workers, mind workers, the standard operating procedures, most of them are not detailed like they are in It can. And it’s very easy to get distracted.

Sometimes those workers are working as lone wolves. In this situation, there was two pilots in there. So it makes you wonder, Okay, I can understand maybe one of the pilots is completely disorganized that day and just doesn’t have his or her mind on the job. But what about the other person? What was it about the culture there or about the open lines or lack of open lines of communication? Did that other pilot even pick up on any of these things that were being disregarded, or were they also completely oblivious to what was going on? I mean, there’s just so many questions.

Yeah, because listening to the fight recording was mind-naming because the number… I just listened to the back to the tail end of it. But the number of things that you would expect, having been in a flight deck many times, have We listened to many other recordings, the number of things that were not happening that you would expect to happen and the amount of questioning attitude that’s drilled in in the aviation space, which is unfortunately not drilled in in so many other industries of saying, Hey, what just happened? What could go wrong here? We just drifted to the left. What could go wrong, assuming our plan is still good?

Right. It was almost like they were colorblind to the red flags that they themselves were creating, and they were just barreling through, whether it be to make up for lost time or whether it be because they were tired. We will never know. But regardless, the outcome is still the same. They unfortunately lost their lives, and then 160 other people lost their lives as well. Their families must live without loss, and everybody else’s family has to live without loss. No one in their right mind would ever accuse these pilots of being willfully negligent or willfully… Neither of them had a death wish that day. They were just two good people who just had a horrible, horrible day that day at work. And we’ll never know why but that’s why I’m so passionate about what I do is because if pilots can do this, where they’re constantly being asked to verify what they’re doing while they’re doing it, if a pilot can do that, what about someone who is working in a mine? What about someone who is an electrical worker or a plumber or someone at a plant? If this can happen to a pilot, it can happen to anybody in any industry.

I would say even probably more likely to happen.

Oh, absolutely.

Yeah. Because there’s less checks and balances than what you see normally in aviation and training and so forth. That’s why this This one is really an interesting one to just explore. I like what you’re trying to do, which is share. It’s not about those pilots. It’s about the learning for others and to see that if it can happen in this industry, it could happen anywhere else. Situational awareness can impact any of us. I think we can all admit that we’ve been at some point where we weren’t fully situationally aware. Where we make an assumption, and we assume the rest works. I’ve worked with some utilities where a team has a really good plan, something doesn’t go to the plan, and then the others are saying, Let’s go. But luckily, one of them says, hold on, we had a plan, it didn’t work. Let’s not keep going because we may have missed something else, which is what I would have expected here, say, well, we made one mistake that was apparent, or two, or three, or four. Any one of them should have said, what else is wrong with our assumption?

Where was voice of reason on that day. That’s just two people who literally have someone in their ear. They literally are listening to air traffic control, and they are constantly being asked these questions. If they can do it, if it could happen to them, it could happen to anyone.

The other part that strikes me is the comfort to speak up. There were really only three people in conversations at that point in time that knew anything that was going on, the two pilots and the air traffic control. And any one of them, and I think this can happen in any industry, I see this day in and out, far worse than other industries, because at least in aviation, there’s things like CRM that are trying to get people to feel comfortable speaking up. But how often do we see something, and we don’t say something? Any one of the three probably could have said something and say, hey, something feels off.

And I think that’s what’s so important about companies Company culture and safety culture is that it does not matter where you are on the org chart, whether you have a title of a manager or supervisor or not. If something feels off, if your gut feeling is kicking in, that is the Lord’s way of trying to protect you. And normally, our gut is usually right. And for us to dismiss those gut feelings, we are doing ourselves and our coworkers and the communities we serve and the clients we serve a major disservice. And we just start disregarding our own gut feelings. And if we’re jaded to the point where those gut feelings aren’t even kicking in, then I can’t help you there. But normally, if people are taking, quote, unquote, harmless shortcuts or doing things their own little way, like, well, yeah, that’s how you’re training We need to do that, but let me tell you how we actually do it. I ask my clients this question all the time, who do you think is more of a liability? The worker who’s been at it for 15, 20 years, who has a ton of experience and who is willfully doing things their own way?

Or is it the worker who is brand new, fresh out of training, who may make mistakes just based on lack of experience or lack of knowledge. In my assessment, I would think it’s the worker who’s been there for a long time, who is just willfully just going on their own little way instead of sticking to standard operating procedures and sticking to doing the work the way it should be done. Because all those rules, all those procedures, those are written in blood. They’re there for a reason. They’re not there to make your job harder or to frustrate you or to annoy you. They’re there to protect you. If people can remember that and keep that in the back of their mind as the foundation of how they make their decisions moving forward, people just need to remember that. For some reason, it’s just so easy to forget, which is why business is always good for me because I’m constantly going into different companies to just remind people of these procedures are there for a reason, and it’s to protect you.

I would say it’s not even willful disregard. Too often, it’s even just drift where We get comfortable. We’ve cut a corner, or something worked. There was no consequence. Like you said, in aviation, the rules were built, were done in blood. There were some crashes. The industry learns more than any other industries, I would argue, in terms of anything that could go wrong, your misses, et cetera. There’s a lot of rules for a reason, but many of those rules won’t have an impact 99% of the time, 99.9% of the impact. You don’t need them. Every industry is the same. But that one time where you do need it, there’s a reason it was designed there.

I think sometimes we get a false sense of security. So many of our processes are done in that Swiss cheese model where if something goes wrong, maybe we have something else built behind it to help mitigate that. But sometimes that can give us a false sense of security and comfort. That’s where the danger really lies, is having that… Competence is a great thing in your personal life but Having confidence in your ability. Confidence can sometimes turn into inadvertent arrogance, and we can’t allow that anywhere. When it comes to work, we can’t allow arrogance to take the place of confidence. We need workers who are confident in what they do in their ability, but we also need workers who have the humility to follow the rules, to have the humility to speak up or take direction when needed, and to do what’s best for everybody, not just personally. Well, I want to get off work here soon, or lunchtime’s coming up, so let’s go ahead and power through this. No, that’s not what’s best for… That may be what’s best for you because you have an amazing sandwich waiting for you in the break room.

But what’s best for the team is for us to do this and to do it the right way. Just having that open line of communication without fear of retaliation is very, very important.

I think that’s an important point because a lot of these themes, like overconfidence, these are biases that all humans have. As we’re successful, we keep saying, okay, we’re good at this. We can do it. And analogy often uses people speeding on the interstate. You know there’s a rule, there’s a reason for that rule. But when I ask any room who has never sped, there’s usually nobody who raises their hand because we accept that five miles an hour faster is okay, maybe 10, whatever the difference, and we start getting comfortable with it because we’ve handled things well most of the time. And most of the time, there is no impact, but maybe one time there will be.

We sometimes get numb to the risks we submit ourselves to. It’s not just a sign of the times. I think it just comes with being at a job or in an industry for so long that you just grow numb to the huge impact everything that you do has on everybody around.

Mercedes, thank you so much for sharing your story, the incident, but also bringing it to the reality that this can happen to anyone. If somebody wants to get in touch with you, what’s the best way for them to do that?

The best way, they can just find me on my website, mercedesromeriusjohnson.com. I’m on all the social media platforms as well, but usually the best way is just to contact me through my website, and I would just love to talk to them about safety.

Excellent. Well, thank you very much for joining the show. It’s a miracle you survived because I think there’s literally, was it five people that walked away from that plane?

Out of 164 that were on board, including the crew and the pilots, only four of us survived.

Only four.

I am very, very blessed to be able to talk to you today and to be here alive still today.

Yes. And being able to share the learnings when I want. So, thank you so much for joining me.

Thank you, Eric. Thank you for having me.

ABOUT THE GUEST

In 1995, Mercedes Ramirez Johnson narrowly survived a commercial airplane crash that killed 160 people, including her parents. She presents her proprietary Second Chance Living concept, an innovative mindset and approach with a proven track record, to organizations such as General Electric, ExxonMobil, Microsoft, NASA, Chevron, and the various branches of the US Armed Forces.

Before becoming a speaker, Mercedes spent nearly a decade in high-level sales in the pharmaceutical and medical software industries. A record-breaking, multimillion-dollar producer, she became the youngest female and sole Latino account executive at Cerner Corporation. She is an active leader in philanthropic organizations, advocating for special needs children and children’s health initiatives, notably for Make-A-Wish and The National MPS Society.

Mercedes and her story have been the subject of considerable national and international media coverage.

Her extensive media experience includes appearances on The BBC, National Geographic Channel, Discovery Health Channel, and as a recurring guest on numerous nationally syndicated daytime talk shows on NBC and ABC. In addition, numerous national magazines and major-market newspapers have run cover stories and special-interest pieces about her, and she was recognized as one of the country’s top young Hispanic up-and-comers by People Magazine’s Spanish Edition, People en Español.

Mercedes and her children reside in Dallas, Texas. To learn more, visit her website https://www.mercedesramirezjohnson.com/.

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Bridging the Gap: Safety Principles from Aviation to Healthcare Safety with Niall Downey

Aug 22, 2024

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ABOUT THE EPISODE

Join us for an enlightening episode featuring our special guest, Niall Downey. As an airline captain and a doctor, Niall shares his extensive experience in both aviation and healthcare to bridge the gap between these critical industries. He explains how aviation’s proven safety principles can reduce human errors in healthcare, offering compelling examples and insights. Don’t miss this insightful conversation that explores the critical topic of error management and how to address it, applicable to any safety-critical industry!

READ THE EPISODE

Real leaders leave a legacy. They capture the hearts and minds of their teams. Their origin story puts the safety and well-being of their people first. Great companies ubiquitously have safe, yet productive operations. For those companies, safety is an investment, not a cost for the C-suite. It’s a real topic of daily focus. This is the Safety Guru with your host, Eric Michrowski, a globally recognized ops and safety guru, public speaker and author. Are you ready to leave a safety legacy? Your legacy success story begins now.

Hi, and welcome to the Safety Guru. Today, I’m very excited to have with me Niall Downey. Quite the experience. A former surgeon who then became an airline captain who’s author of books in this space. Great experience, great stories. Niall, welcome to the show. Very excited to have you with me.

Thank you, Eric. It’s great to be on the podcast. I’m a big fan of it.

Now, first we have to start surgeon. It’s a credible profession. You spend years becoming a surgeon. How do you go from being a surgeon to becoming a pilot?

Well, I trained as a doctor in Trinity College in Dublin, in Ireland. So that was a six-year course. And then I subsequently trained then as a surgeon between Dublin and Belfast. So, I got my fellowship with the Royal College of Surgeons in Ireland when I was in Belfast and subspecialised then into cardiothoracic surgery, so hearts and lungs. I then moved back to the National Cardiac Unit in Dublin in 1998, that would have been then, and spent about a year there. But the way the system was in the ’90s in the UK and Ireland is that you worked… It’s the equivalent to a resident in the States, it’s called the Registrar. But to progress on then to become a consultant or an attending, you had to get what was called a Specialist Registrar Post. So, you call it specialist, trainee. That was actually the exact same job, same hospital, same patients, same money, but it was recognized differently on paper. And unfortunately, if you didn’t get the training job, you had absolutely no chance of progressing. I’d already tried the States at that stage. I’ve been shortlisted in Mass General. But again, they offered to let me work there, but it wouldn’t count as training.

I’d already tried the UK. I’d been in touch with people in Australia. So, there was no problem getting work, but there were no training posts. And then when they shortlisted the post in my hospital in Dublin, I didn’t make the shortlist. So, I read between the lines and realized that I wasn’t being considered there either. So, they were happy to employ me in one of their private hospitals operating on their patients, but not to give me a training post because I It’s such a shortage of them. So, I was such a shortage of them. So, I was left. Basically, I could see my career coming to an end after 12 years of training. And the following Sunday, the Air Lings is had an ad in one of the Sunday papers looking for cadet pilots. I saw that it was all chest in aviation, no background. I saw the ad and thought, right, let’s pursue that.

And so, a life flying around the world followed.

Well, it started, there was four and a half thousands of us. Excuse my cough, because hay fever. Four and a half thousands of us applied for 30 posts, and I got in number 11. So, then we went off and spent about 14 months training between Oxford in the UK and Arizona in the States and came out the far side then with the professional license. I think it’s then trained me on to the Airbus A320 fleet and been progressing through the system for the last 25 years, basically since that. And I’m now the captain on our A330 fleet. So doing transatlantic flights out of our Manchester base in the UK at the minute.

And so incredible connection because very few people I’ve come across understand that depth of safety in aviation and how safety has gone to where it’s at now. At the same time, on the side of health care, a tremendous opportunity in terms of connecting both. So, tell me a little bit about some of your experience in terms of applying the principles of safety from aviation that are proven, have worked, deliver incredible results to health care. And we should start with your story around the chief exec in the NHS, because I think that was a great introduction to it.

Basically, it was a bit of a culture shock. Was I actually in aviation a couple of years before it really sunk in to me what was going on? It’s a whole different mindset. I think the chief executive story, maybe the one a couple of years ago to start a COVID, I volunteered back into the NHS to go back and work as a doctor because we kept hearing how short staff they were. And after pursuing the local hospital Trust for about six weeks. The fancy told me that they weren’t short of doctors. Thanks for offering. So that’s why I ended up writing the book. I basically had all the spare time in my hands. Sixty flights a month has become one return flight a month to Heathrow. So had to fill the time somehow. So, I started writing the book. And then last year, so a couple of years down the line, I was given a presentation to the chief executive of the trust and the whole C-suite. And I explained at the end of the talk that my book was about to come out and that I volunteered into the trust and had been told that I wasn’t needed.

And it was the first she had heard of it, and she wasn’t impressed.

I’m sure in the height of COVID, that would have been quite an extra pair of hands.

Well, it would have been, at that stage, it was quite a while out of clinical practice, so I wouldn’t have been much use there. But I certainly had things that could contribute.

Tell me a little bit about how you’ve been able to apply the principles from aviation safety into health care.

Basically, the business set up is called Framework Safety Group. And the reason I call it framework is that in aviation, we have a framework that we fall back on. So, if anything goes wrong or even when things are going right, we have a framework approach. So, there’s three big legs to the stool. First leg is our reporting system. In health care, if you make a mistake, it’s generally name, blame, shame, retrain. In aviation, we’ve got it. The just culture means that I can put my hand up and report things without any worry about disciplinary action or any dismissal. That is taken as a genuine mistake. Now, it doesn’t cover gross negligence and it doesn’t cover malicious harm. So, it’s not a get out of jail free card. But if I make a genuine mistake, I can put my hand up, safe and knowledge that I won’t be targeted for it. We then, second leg of the stool then, is we then take a systems approach. So, in health care, the second step is generally who went wrong. In aviation, the approach is what went wrong. So, the logic for them will be, well, you’ve been flying for us for 25 years.

If you were a crab pilot, you’d have made that mistake long before now. So, what happened today? And we look into the system. I’m usually find that there was a trip wire in the system that I fell over. And we try and engineer it out and replace it with a safety net if possible. They try and prevent the same thing happening to a colleague further down the line, which is why we’ve made such progress and health care tends to stagnate because they don’t get to that process. And then the third leg is our crew resource management, our CRM philosophy, which is how we actually manage our earners. And staff are taught that from day one and it’s recurrently trained throughout your career. So that’s the three legs of the framework. And I think that framework is very transferable in two basically any safety critical industry, including health care.

Yeah, I think that’s the part is A lot of the learnings from aviation, phenomenal learnings, they’re transposable in every industry, but not a lift and shift. It’s not exactly the same. It’s adapting. I think the challenge I’ve seen in many industries is this desire that unless it’s been created in my own industry, it doesn’t apply, it won’t work. So how have you been able to broach that? I mean, you have the benefit of understanding health care like few others can, while also have that aviation background.

To be honest, Eric, it’s been a hard sell. I spent 13 years on this now, and it’s only in the last year since the book came out, I’m really starting to get any traction at all. I basically need someone just to buy the concept. Now, at the minute, I’m working for a big private hospital group in Dublin. The chief executive got in touch earlier this year. And by luck, he used to be one of my consultants when I was in cardiac surgery in Dublin. He was a cardiac surgeon up until last year and then also chief executive of the biggest private hospital group in the country. So obviously, we already knew each other from our previous careers. And he’d read the book and he’d heard a few other podcasts had done and read a few articles. And basically, I agree with the concept. I bought the whole idea. He’s asked me to come in and try and apply it across their whole hospital network, which we’re a couple of months into the project now at the minute. So the first step is that you accept that there is room for improvement and that the aviation approach can be transferred.

So that’s been a great start. But generally, it’s very hard to get healthcare to buy the concept.

I think that transposes to a lot of other industries as well, because I think any high-risk, high-reliability industry needs to be constantly looking for best practices. Aviation is one of the few, I think, you can show where there’s been a significant leap, even if you look backwards in the 1960s to how it operates today. Very, very different operating environment. Tell me a little bit about each one of those tools. You talked about just culture, and I’ve had quite a few podcast guests talk about just culture. I think what you share is incredibly important, this element that if you want to be a learning culture, learning environment, you need to have people comfortable raising concerns, raising mistakes, and that’s harder than it looks.

Yeah. And I said just culture is what’s transformed aviation. I think we need to be careful that we don’t get complacent about it. I think the way Boeing have gone for the last few years has been a great example of where it can go wrong. That the just culture In Boeing, it doesn’t seem to have worked for the last 15, 20 years. And it doesn’t have problems quickly. It tends to accumulate over time. I think we’ve seen now recently with, say, the 77 max, and so instance like that, now that These problems have been gradually accumulating. And it’s like the Swiss cheese model. Eventually, you get enough holes of cheese lining up that it starts to cause problems. I think that’s the stage I’ve got to know. I think it’s a great lesson for all of us that just culture is great, and the aviation approach is great, but we need to keep working on it. We can’t get complacent. If you get complacent, it falls apart. So, it’s a progress, a whole evolutionary process that we need to keep moving. If we try and stand still or think we’ve achieved all we need to achieve, it stops and it retreats very quickly.

But then I think the just culture has been the game changer for us. Because you can put your hand up, you can become aware where the problems are. You can’t solve problems if you’re not aware that they’re there. So, the just culture lets us know what the issues are, and then we can start addressing them.

And I think your example, your connection to the Boeing one is an interesting one because even in some of the recent testimony that was heard, the references people are talking about is they didn’t feel comfortable speaking up, raising concerns, which is very much counter to the just culture. Something must have gradually introduced over time where those data points that you want so you can address the system weren’t coming through.

Yeah. So, we have to be careful not to think we’ve achieved all we need to achieve and stuff. We need to constantly keep moving. With the just culture then, because we have the reporting system, and basically the reporting system is shared far and wide. One of the examples I use is the Air France crash back in 2009 when the Airbus A330 crashed into the Atlantic. Our planes have telemetry like Grand Prix cars. So, they send information via satellite. They like live while we’re flying. So, it goes back to the company’s headquarters, so Dublin in my case, and to the factory, so Toulouse for Airbus this case. So, in their case, the black boxes weren’t found for two years, but using the telemetry, they had a rough idea of what had happened, and they managed to put a picture together of what they thought had happened in the accident. So, we were actually training the accident within about three or four weeks of it happening. For a comparison, there’s a study done in Cambridge, in the UK, a few years ago. Into health care, and it shows their reaction time was about 17 years.

Wow.

So, if you like it, we’ve written a paper, and here’s the new gold standard of how to do something. It takes seven years before it’s applied across the coal face, by which stage it’s probably obsolete. Where I say, with the Air France crash, worldwide, all Airbus operators were training the new system within three or four weeks of it happening. And that training has now been incorporated into our current training every six months. So, it’s called the UPRT, Upset Prevention and Recovery Training. We do that now every six months in the simulator. And we’ve been doing that now ever since 2009. And touch wood, so far, we haven’t had the repeat of the Air France crash.

You just highlighted something I think that’s also… It’s not directly one of the three stools, but I think it’s key that I hear in aviation compared to a lot of other sectors, is this constant simulation, retraining. It’s part of it. In too many industries, what I see is you get qualified, and then you stay qualified for the next 50 years, whether or not you’re capable or not to do it, versus here, you’re constantly going through scenarios, simulations, learning.

Yeah. Again, that was a tie in with the CRM, but then we’re constantly looking to trap error and avoid trap litigate. So, the training then because the just culture means we can speak up, the reporting system then lets us know where the problems are. And then that information is then found into the training department. So, they then actually construct the simulations around what’s been happening in the industry and around the world so that we can train relevant stuff. And worldwide, we generally have the same aims. They say the World Government Body has identified six big headings of things we need to focus on. One of them, say, being runway incursions, which has been a big issue in the States over the last 6-12 months, even. We had the Japan crash in Tokyo back in January this year, which was down to a runway incursion. Now, we’re aware there’s a problem. It’s been highlighted worldwide. And we have five or six new safety nets built in to try and address that. And it is getting better, but it’s still not perfect. We’re still having accidents. We’re still making mistakes. So again, the idea of the simulation and training is that we put ourselves in the scenario.

Here’s the mistake coming. Or here’s not even necessarily a mistake, just here’s something failing on the airplane. Do you know how to handle it? And again, the framework approach, because in the past, there used to be specific things we would train. So, you knew that were coming up and you revised them, and you turned up at the simulation exam and you knew what to expect and you performed as expected. Then we realized, well, that’s not really very realistic. And that’s what happened in the Air France crash. Something happened that they hadn’t seen before. And then because they hadn’t done it in the elevator, we’re, well, now what? So, it’s in the last 5-6 years now, certainly in Europe, we’ve changed the system. We’re now looking at evidence-based training, EBT. So, we’re now looking at training, again, a framework approach that now, instead of having set scenarios, we’ll have something happen. And even the instructor doesn’t know exactly what the details are. They’ll have a list of scenarios. They’ll pull one out of the envelope and say, Right, this is what’s happening in this one. So, they’re not even aware what’s coming next. So, it means then you can’t go in prepared for it.

And it’s actually improved the training an awful lot. I go in with an overall framework approach. So, here’s how we’re going to address any general problem, and then we’ll fine tune it according to what the actual issue is. And St. Harling’s has been one of the leads in Europe for implementing that, and it’s been very successful. Now, there’s a lot of simulation coming in now in health care as well. And I think that’s a great thing. When I trained it, we see one do one, teach one. I learned to saw chest open by saw chest open. It’s great now that you can actually do it in a simulated low-risk scenario now where you can actually be trained to do it. And if you do it wrong, you can stop and repeat. So, I think that’s one of the big thing’s health care has taken out of aviation so far. Health care means that they are making progress. I just think they could be progressing faster. And there’s a lot of mistakes we’ve made in aviation and in other states of critical industries. And we’d like to share them with them so that they don’t have to make the same mistakes and learn the hard way.

So, you touched a little bit on the Just culture. Love to hear you talk a little bit about the systems view and systemic approach to safety, because I think that’s another big theme to focus on, as well as when you mentioned the Swiss cheese. So, can you elaborate a little bit more in terms of the applicability of some of these concepts?

Yeah, well, the systems approach, again, is the second big leg of the stool. And it’s critical to the way we do things. So, to simplify it right down, instead of looking for who went wrong, we look for what went wrong. In a lot of the health care scenarios, the medication errors have been a big issue for the last decade or so. And from talking to staff, you often find that there was a medication error, they gave the wrong dose or a wrong drug. The investigation, so looked at it and find, let’s say the nurse made an error. She calculated the dose wrong; she gave the wrong one. And it’s not right, okay. So, we’ll retrain the nurse in how to do arithmetic, basically. And that’s a little bit of retraining. And then we send her back out. Now, that’s basically a very simplistic approach of who was the last person to touch the ball and they take the hit on it. In aviation, we look, okay, that person made the mistake. Now, they’ve been here for 15, 20 years. Why did they make that mistake? And then we look and see, right, well, what else was going on?

And you are often I found then that there was a case I was involved in last year. They made a mistake in a hospital. It was investigated and they decided that the nurse had given the wrong dose of the drug. So, the solution was that the nurse now, or all the nurses on the unit, now They have to cross-check certain drugs with one of their colleagues before they’re allowed to give it. And it didn’t really work. When you dug a bit deeper. What actually happened, it’s post-COVID now. A lot of specialist units have lost a lot of their experienced staff. They have less experienced staff now on the They’ve got agency staff coming in who are not used to working in that ward. The experienced staff are trying to mentor them. They may be looking after more patients than they have in the past. They’re missing breaks, they’re missing meals. We all make more mistakes when we’re hungry, angry, late, or tired. You find when you actually look into it a bit deeper, the real reason that the nurse made the mistake that night is that she was too busy. And then you think about then, how was it resolved?

They made her busier. So again, that’s not going to work, and it didn’t work. So, in our case, then we would then look back another few steps. Again, you mentioned the Swiss cheese idea. They found the first hole in the cheese and stopped there. What we need to do then is keep digging back and saying, well, where were the other holes? So, there might be about five layers of the Swiss cheese. Now, getting the nurse to cross-check the drug, grand, there’s one of the holes filled. But what about the other four or five? It might be a lot more efficient to fill those instead. So that’s the whole idea of the systems approach. We work out what went wrong on the night and how can we improve that. And again, if I can even get that across to health care, that will transform it because a lot of staff feel victimized and blamed. When they make a mistake, health care staff are very hard workers. They’re very dedicated. They come to work to do their best. When something goes wrong, it affects the patient, but it also affects the staff member. They’re going home now, that night thinking, well, I injured a patient.

I’ve had a very bad day at work. You find then the retention rates drop. If you can try and avoid them getting blamed for it, that even if the mistakes still happened, that they’re not held responsible, we work out, well, how can we improve this for everybody? You find that the staff turnover reduces. It’s easier to keep staff there and overall staff satisfaction improves. There’s been studies done that when people are under investigation, that the suicide rates go up as much as fourfold just because they’re being investigated. So called the second victim. So, the system is one big way of addressing that, that we’re not blaming you, we’re blaming the system. Can you help us find out why you went wrong that night? Because it’s obviously not just your fault.

I think it’s a key because I see this across industries. So, it’s not just a health care piece where you go look at the last line of defense, the last hole in the Swiss cheese, and blame that person. It’s the easy one because it’s very complicated to go and understand all the various system factors that came in. But also, to what you just shared, it means that safety is a team sport because now you’re looking at HR. Hr had responsibility even in terms of scheduling, in terms of looking at skills and capabilities that are on shift. It’s starting to extend the role of safety to beyond just the critical staff at the front line.

Yeah, and I would extend it even further. I would extend it out to the patients and to their families as well. The line I use now is that the healthcare is not a spectator sport anymore. The guy did a TED talk in Stormont in Belfast here back in 2016. Part of the idea is that we had to widen the whole idea out that it included patients and staff. So, you might have, and I’m not sure about in the States, but in the UK now, you can have maybe two staff nurses looking after a ward of 30 patients. Their attention is going to be severely distracted. The patients looking after one person themselves. So, if they see something that they think isn’t correct, they should feel comfortable speaking up and saying, I’m not happy with this, or just like, I’ve noticed this. Is that okay? It doesn’t have to be an accusation to the staff member that you’re not doing your job properly. It can just be a help that, I’ve spotted this. I’m not sure that’s correct. Do you want to have a look at it? So, you’re an extra pair of eyes. Family members the same.

So, we talk about crew resource management. We have a very broad definition of crew. From the health care point of view, we see it as all the staff on the wards, the porters, the cleaners, the admin staff, the patients, their families. Everyone has an input. Everyone has an opinion. So, if we bring that opinion to the staff and let them basically benefit from the knowledge that the patient has. And as well, patients all have multiple comorbidities. They know how they interact. Staff member generally doesn’t. Everybody’s slightly different. So, the patient is the best judge themselves of how they feel. And we should encourage them to contribute. They don’t make the final decision, but they’re certainly a partner in the decision making.

Right. Nothing about me without me, as they say here.

This episode of the Safety Guru podcast is brought to you by Propolo Consulting, the leading safety and safety culture advisory firm. Whether you are looking to assess your safety culture, develop strategies to level up your safety performance, introduce human performance capabilities, re-energize your BBS program, enhance supervisory safety capabilities, or introduce unique safety leadership training and talent solutions, Propulo has you covered. Visit us at propulo.com.

I vaguely remember when we talked about you had a stat around the number of prescription errors in the UK.

There was a story in the BMJ years ago. It showed 237 million errors in NHS England, which has 55 million people.

That’s crazy in terms of the volume. And it goes back to you’re never going to save it just based on the last line of defense.

That’s the problem. If you rely on the last line of defense, it’s not going to work. One of the examples I give in my talks is a lot of medication is very similar packaging, very similar labeling, very similar short presentation. And we wonder why people make mistakes at four o’clock in the morning when they’re tired.

Yes. Who wouldn’t make a mistake at four o’clock when you’re tired?

Mistakes are inevitable. That’s how we manage them, the counts.

It’s the same as a pilot with fatigue. It’s going to happen; jet lag is going to happen to So a pilot just like it would to anybody traveling across time zones. But you just don’t want that to be a critical failure.

I miss about two night’s sleep a week. When I fly back from the States, I fly back through the night and land in about six or seven o’clock in the morning. So, I’ve now been up all night. And that happens one or two nights a week. So, there’s an accumulated tiredness there. But we factor that into our decision making. Say when we’re coming in to make an approach into Dublin, like I mentioned to the co-pilot. So, we will do a brief. Here’s how we’re going to get in. Here’s what we’re going to do. And the risks are, right, okay, it’s five in the morning. We’ve been up all night. We’re tired. Keep that in mind. If you see anything you’re not happy with, speak up early. Don’t assume that I spotted it and I know what I’m doing. It might be something I’ve completely missed because I’m tired. But you’re a second, again, bring the patient into it. You’re a second pair of eyes. At least highlight to me that there’s something wrong. It might be something I’m quite happy with but raise the issue with me so I’m aware of it. It’s about sharing mental models.

And that, I think, is a good tie into your… You talked about CRM operating philosophy. Can you tell me a little bit more about some of the principles there and how they would translate to other industries, including health care?

Well, the CRM can be broken down in different ways. The traditional way we’ve been using for quite a while is six big headings. So, they all overlap, really. But there’s communication, leadership, stress and workload management, then decision making, situation awareness, and threat and error management. So, all research has shown that communication counts for by 70 % of issues or adverse events in all safety critical industries, including health care. So, if we can even focus on that. Now, the communication, it sounds like it’s very easy. It’s actually not. It’s a main field. One of the examples, I play a video to the staff yesterday, same when it was presented. I don’t think you have it in the UK, or in the States, rather. It’s the two Roni’s. Now, there were two UK-based comedians, and they had a sketch show. One of the sketches is that William comes into the hardware shop and ask the man behind the counter for four candles. So, the guy goes and gets four wax candles that you can light to take home with you. And there’s no four candles. He says, Yeah, well, there you go. Four candles. He says, no four candles.

Handles for forks in the garden. He wanted a new handle for his garden fork.

Four I explained in the staff.

So, there’s three stages. There’s the communicator, there’s the message and the receiver. The communicator passed on a very clear message, which the receiver heard because he even read it back, but he misinterpreted it. So, what you think may be a very clear message to a patient. They might actually have interpreted something completely different out of it, despite the fact you’ve given them a very clear message. So, the communication science is dead easy. It’s not. So, in aviation, we have a readback system to try and make sure that we’ve definitely heard it properly. Even then, that can be misunderstood. I can read it back, but I can still interpret it differently. So, if we’re very keen then that we try and get feedback from patients that know, so what do you understand is going to happen today? What are your concerns? And try and work out. Those are the same as the message that’s actually been processed. So, we focus a lot even on the specific terminology. In aviation, in theory, we all use English. Practice is not that simple. If you’re in Spain or France, they’re speaking local language. But what we do is we have a very limited vocabulary.

We reduce the number of words we use, reduce the amount of confusion. We give simple instructions at a time, maybe one or two at a time. We don’t go beyond that. We try and keep it as simple as possible to avoid. So, communication is critical. We actually get trained in communication. Healthcare staff don’t. And also, we’re training… We’re communicating with other people who’ve been trained in communication. Health care staff not only don’t get training, but they’re also dealing with members of the public who haven’t been trained. So, it’s a double jeopardy, really. It makes it twice as hard for them. So, I think that at least if we can train the health care staff, they can try and improve their end of things, that they’re aware of where it can go wrong. And that also reduces the… At least they’re aware then of the possibility of misunderstanding in the other side. They try and reduce communication problems. Now, again, you’ll never resolve it completely. But this is all about trying to improve things, not change things. We’re never going to reach zero harm or zero errors. But there’s certainly room for maneuver. Health Our own research shows that we can reduce the number of adverse events by 70 % by using aviation safety techniques.

But a lot of them are still pretty reluctant to actually use those techniques.

Your point on communication, I think, is really good one because there’s a lot around how much I share in information, the language I use, so you don’t introduce risk by removing or introducing words by choice of words, and also the readback, the checkpoints around, how I communicate, have you understood, and does it match my instructions?

Even a simple word, if you look at the actual vocabulary, one word that we try to avoid is left and… When something is correct, saying that it’s right, because then you get an index, say, one of the examples I use in my book, as I say, somebody goes in to get a kidney removed and they’re getting to say they’re left kidney removed, but they remove the right kidney, but the right kidney is the wrong kidney. So simple words like that. You’re used to write having two different meanings. So again, you’ve opened a risk of misunderstanding. And if you can try and avoid that. So instead of talking about right and wrong, talk about correct and wrong. And again, there’s one of the holes in Swiss cheese filled already. They’re very simple things like that. So, if you’re aware of where they can go wrong. I simplify a lot of my training down to the two comments, basically. Where can this go wrong? And what’s plan B? So, if I’m talking about right and wrong, you can misunderstand what I’m talking about and think right as in right side, when we maybe should be operating on the left side.

So, to avoid me introducing that misunderstanding for you, let’s just not use that word at all. There’s plenty of other words we can use. Correct. Again, it sounds very pedantic, but in aviation, we are quite pedantic about stuff because, again, Yeah, absolutely. If I make a mistake in health care, I can kill a patient. If I make a mistake in aviation, I can kill 300 people and I’m going to be one of them. So, a guy could skin in the game. So, we’re very keen on the terminology we use. We tend to spell things out even phonetically. So, if I’m being cleared to a certain waypoint, we’ve got checkpoints in the sky, they’re motorway junctions, basically. I can be cleared to take a shortcut to one of those junctions. A lot of them sound quite similar. So, we’ll actually spell out the name. If we’re not sure, we’ll spell out the name of them and we’ll spell it out using the alphabet. So, if I say M, that can sound very like N.

Yes, very similar.

So, I’ll talk about Mike or November, which is a lot clearer to understand. So again, we can see where the potential for misunderstanding is. So, then we try and what’s plan B? We resolve that by using the phonetic alphabet when it’s appropriate.

I mean, Tenerife is a great example of miscommunication even and how choice of words can have a significant impact.

Even like Tenerife, again, when you look at it, it was, again, your classic Swiss cheese. There was about six or seven different layers. And if any of them had been addressed, the accident wouldn’t have happened. But from the communication point of view, there was fog, so the tower control couldn’t see the planes. So, you’re relying on the actual words. One of the instructions he gave the KLM was after takeoff, he was told what he was to do next. He was basically given instructions. But the only word the captain and KLM heard then was takeoff. So off he went. So, the terminology has now changed. When I arrive at the runway, I’m not ready for takeoff. I’m ready for departure. And the only time… Again, it’s great. I’ve heard it used. I was in Orlando a couple of weeks ago, and I heard a pilot using the wrong terminology, even 50 years down the line. But I would now arrive, I’m ready for departure. I’ll then be cleared to line up and I’ll be cleared for takeoff. And the only time we should use the word takeoff now is when we’re cleared for takeoff. So, there’s no misunderstanding.

I think this is a very good example, because if I remember in Tenerife, there was also noise on the radio and an intercept, so some words could have been missed as well. And if you hear the word, take off without the context, it could also drive a mistake.

Yeah, what happened there is they got our two-way radio system, I can only carry one voice at a time, or if it tries to carry two, it ends up garbling. So, the man was cleared or given instructions after takeoff, and that’s okay, clear for takeoff. The If Han Am, who’s on their own, may come in towards him, realized, no, hang on, he’s now taken off and we’re coming towards him. So, he actually called the tower. Can you just confirm? Has he taken off? But the tower was also calling back as well because they’d realized there was a misunderstanding. So, they ended up taking over each other. So, nobody heard anything. But again, that’s one of the risks of two-way radio. So again, it’s another hole in the cheese, but at least you’re aware of it.

Yeah, exactly. And I think that mindset around the Swiss cheese forces to think about what could go wrong in all the various elements, not just the last decision.

Because, again, especially in, say, transatlantic, now there’s a lot more traffic. So, we now have a text message system. So, a lot of our communication with air traffic control now is done by text message, which frees up the radio. So, there are less people competing on the radio.

Phenomenal examples of how you can take aviation examples and bring it to health care. But I would say any other industry. All of these principles apply to any other high-risk industry and is, I think, the next leap of performance from a safety standpoint. Tell me a little bit about your book and if somebody wants to pick it up.

The book is called… It’s about errors. So, I thought, what would you call the book about errors? Oops. Why things go wrong? And it’s about understanding and controlling error. So, it’s available in the UK. It’s available in the shops. It’s in Waterstones. It’s in all the independents. In Ireland, it’s in Easton’s and all the independent shops. And in the States, Burns & Noble are carrying it on their website, but not actually carrying it in stock in the shops. It’s available on Amazon as well. And the e-book format has now come out in the last couple of months as well. So, it’s available now on Kindle or Nook for Burns & Noble readers. It’s on Apple Books and various other platforms. So, it’s accessible either in hard copy or an electronic copy.

Thank you. Thank you very much now for joining me today and sharing some of your experience and the connection. I really do encourage a lot of other high risk industries to really look at how can you bring some of the learnings from aviation because there’s been a substantial leap in performance by learning, by creating this just culture where people are comfortable speaking up, by looking at the system, as you mentioned, but also from an operating philosophy, a lot of great learnings there to carry into any industry. And when you mention that in Well, in health care in the UK, there’s a lot of… Sometimes people are saying there’s too many pilots talking to us. To me, that’s a good thing because at least there is that connection. There is a desire to do more. So, tell me a little bit about how that came about in terms of health care starting to look at aviation.

Well, I think they’ve been aware that with someone to contribute for a while, but there was very little input. One person who’s transformed the whole approach is a friend of mine, Captain Martin Bromley. He’s a captain with British Airways in the UK. His wife, Elaine, went in for a routine surgery. I think it’s over 15 years ago now. Elaine was only about 35, and she was just gone in for a routine ENT surgery. And she had an experience team working with her. Two anesthetists were putting her to sleep before she went for the surgery. They tried to intubate her and discovered then that they were having difficulty. It was a difficult airway. And it became, it can’t intubate. And normally there’s procedures for that. There is a plan B. The staff there had a trolley that would allow them to do a tracheostomy, which would basically open a hole in the front of her, in front of her airway, and at least establish air going into her lungs and into her brain, more importantly, which then stabilizes the situation. And you’ve now bought quite a bit of time to actually try and address it.

But fortunately, when someone goes badly wrong, our brain is wired by evolution. Evolution, we’ve been evolving for about 200 million years now. The brain evolves very slowly. Healthcare and say, aviation has evolved very, very quickly in the last 100 years. So, our brains haven’t really caught up. So, we’re doing very complex, very high-tech stuff with a brain that’s running on caveman software. So caveman software is basically you go straight in the fight or flight. It’s the amygdala hijack. Your forebrain gets frozen out of it and your hindbrain takes over. So basically, if you’re out in the Savannah and you turn and you see a lion running at you, you don’t want to sit and analyze that and decide, well, what’s the best approach here? It’s straight into fight or flight. When you have a patient who crashes in front of you, it’s the same thing. You immediately panic and go in the fight or flight. First, that’s not a good long-term prospect. So, say after the Air France crash, Airbus brought in a new procedure called the Golden Rules. So, it’s basically then, we look back, we look, aviator, navigate, communicate. It’s our version of airway We’re even in circulation.

Check, is the plane actually in a position that’s capable of flying? Are we pointing at a mountain? So, communicate with the people around you. Check if your autopilot’s working, check the automatics and stuff. So, we now default into that. That takes about 10 or 12 seconds, and that gets over the start of reflex, and we can then analyze things better and get our frontal cortex involved. Health care that day didn’t have that in place. So, they went into the fight or flight response and never really got back out of it. There’s two in this involved who were very competent, very experienced, and no doubt doing their best. But they ended up with tunnel vision of what was going on. They had a couple of theater nurses beside them offering them the tracheostomy kit, but they were so focused on what they were doing. They basically went in the tunnel vision and couldn’t hear what was going on around them. Unfortunately, Elaine ended up suffering brain damage and died in intensive care a few days later. Since that, Martin has then brought the whole aviation approach to the NHS in the UK. He produced a video, just a routine operation, which I think is now used in the induction of all new staff in the NHS across the board for the last decade.

And Martin has made phenomenal progress. I then set up a group called the Clinical Human Factors Group, which does a lot of training around the UK and trying to bring the human factors idea into health care. I say Martin’s probably done more for this aviation approach in health care than the rest of us combined. He’s made phenomenal progress. Hopefully, I’ll be standing on his shoulders and try and take it a bit further as well.

Thank you for sharing that. Thank you very much for joining me today.

Thanks, Eric. And see if people want any further information, my website, frameworksafety.com, has various articles written. And am I allowed to say that there’s some other podcasts on it as well? Other podcast articles?

Absolutely. Of course you may.

There’s information on that. If anyone wants to get in touch with me with any suggestions or ideas, I’m all ears as well.

Excellent. So frameworksafety.com?

That’s it. And I said there’s links to the book, there’s links to the TED Talk. There are various articles and so on I’ve written there. And I’m very interested if people have any feedback or any comments. Again, I’ve only got a certain amount of information. If people have other ideas or criticisms, I’m very happy to receive.

Thank you so much now. Incredible experience between experience as a surgeon and now as a captain on an A330.

Thank you, Eric. Thanks for having me. Hope you find it useful.

Definitely. Thank you.

ABOUT THE GUEST

Niall Downey qualified as a doctor from Trinity College, Dublin, in 1993. He trained as a surgeon in Belfast and received his FRCSI in 1997. He was a trainee in cardiothoracic surgery, working as an SHO in the Royal Victoria Hospital, Belfast, before returning to Dublin, where he worked as a registrar in the National Cardiac Surgery Unit in the Mater Hospital and Our Lady’s Children’s Hospital, Crumlin.

He subsequently retrained as an airline pilot with Aer Lingus in 1999 and combined aviation with medicine by working as an Accident & Emergency doctor for six years before focusing fully on aviation. After operating as a co-pilot on both the European and Trans-Atlantic fleets, he qualified as a captain in 2010. He is currently operating out of their Manchester base on the Airbus A330 Trans-Atlantic fleet.

In 2011, Niall formed Frameworkhealth Ltd, a company providing aviation-style safety training modified specifically for healthcare, which draws on his thirty-five years of experience in both industries. This project aims to share aviation’s Safety Management System with healthcare to address the huge issue of Adverse Events, usually caused by systemic faults but often blamed on the last individual to have touched the ball. Niall aims to encourage healthcare to adopt a Just Culture, embed a systemic Human Factors approach, and empower patients and their families to speak up as part of the crew. He has spoken at many conferences locally, nationally, and internationally.

In 2023, Niall published his first book, ‘Oops! Why Things Go Wrong,’ which explored the increasingly topical issue of error across industry and society generally and, most importantly, how to address it. The book is already in its second print run after a higher-than-anticipated demand.

The book’s success has led to many invitations from outside healthcare, and Frameworkhealth has now evolved into Framework Safety Group Ltd in recognition of this broadening scope.

More information is available from www.frameworksafety.com

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