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Proactive Aviation Safety SystemsHow other industries use aviation conceptsBy Terje Lovoy, consultant and lecturer working with high reliability organizations

Phone +47 41374000 - e-mail: terje@lovoy.info

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ClearComplex

AGENDA

How some industries have used aviation concepts to improve safety more than 40%

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I will share personal research, conclusions and data from governments and organizations . Internal company case studies and

data are only from companies who agreed to share the facts.

Photo by Terje Lovoy

4

HOW SAFE IS FLYING?

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• Statistically you must travel every day for more than 8000 years to experiencea major accident

• You are more likely to be struck by lightening

• Safest way to travel

Photo by Terje Lovoy

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HISTORICAL DEVELOPMENT

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Yearly hull losses per million flights

0.32One accident for every

3.2 million flights

Sources: Airbus, FAA and IATA

First mostly technical improvements

Human factors improvements

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THE REMAINING PROBLEM

Knowledge is there but not used

Photo and illustration by Terje Lovoy

80%Human error today

FROM SUPERIOR CAPTAINS TO TEAM

New CRM training:

Leadership

Communication

Co-operation

Teamwork

Threat and error management

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CRMCrew Resource Management

Photo by Terje Lovoy

818.09.20161988 – forgot flaps and checklist complacency

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IN-FLIGHT FIRE ACCIDENT COMPLEX 208 STEP PROCEDURE TOOK TOO LONG

1998Photo source Wikipedia

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IMPROVED AND SIMPLIFIED HARDWAREBUT PROCEDURES GOT MORE COMPLEX

Photo source Terje Lovoy

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THE SOLUTION WAS TO SIMPLIFY

Typical modern airline checklist before landing

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OTHER INDUSTRIES ARE ALSOSTRUGGLING WITH COMPLEXITY

Photo by Teekay Shipping – used with permission

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DEEP DIVING

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5 WHY ROOT CAUSE ANALYSIS

Problem: Human error

1. Why – because they did not follow procedures

2. Why – because the text was not user-friendly

3. Why – because it was too complex

4. Why – because procedure writers don’t know how to write concise

5. Why – because of no writing standards or training

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SPAGHETTI TEXT

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Different people makingcontinuous modification

causing tangled structure branching through

documents.

Photo and illustration by Terje Lovoy

Mixing strategy, accountability and execution

ResponsibilityTasks

Policies

Roles

BREAKING SPAGHETTI TEXT INTO BITE-SIZED PIECES SO WECAN MORE EASILY DIGEST IT

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Original contentOften based on complex law text not intended for operational use

After chunking

GROUPING AND ORGANIZATION

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Un-chunked example from an operational manual

AFTER CHUNKING

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Step-by-step

Process oriented

Logic sequence

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SIMPLICITY IMPROVES SHIPPINGNAVIGATION HANDBOOK

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LESS CAN BE MORE

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TEXT WASHING PROCESS

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From 46% passive text to 95% active text

PROACTIVE + CONCISE = PRONCISE

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User-Friendly Procedure Design Case Study Video

YouTube Link https://www.youtube.com/watch?v=VLPQ6yE3fSE

With permission from Eidesvik

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Medical complications reduced by 42%

”Biggest breakthrough since doctors began washing hands”Image by TV2 with permission

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Separate

Untangle“spaghetti text”

Organize

ChunkingProcess orientedRisk based

Text wash

ConciseProactive

Illustration by Terje Lovoy

Training

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Proactive Aviation Safety Systems How other industries use aviation concepts By Terje Lovoy, consultant and lecturer working with high reliability organizations, Phone +47 41374000 terje@lovoy.info

Slide 2

What would you say if we replaced the traditional speed limit signs with a wordy law text so complex that you cannot read it before you pass it? Most will agree that this will not improve road safety. It is with people like text, some talk a lot but say very little. We have words for this in every language. In English, we call them windbags. To be called a windbag is not a compliment. Most high reliability organizations still often have windbag text in their procedures. If people do not comply, we get frustrated since we make important procedures but our people do not follow them.

Slide 3

In this presentation, I will discuss aviation safety and how other industries have used aviation concepts to improve safety more than 40%. I will share personal research, conclusions and data from governments and organizations. Internal company case studies and data are only from companies who agreed to share their facts.

Slide 4

But first, how safe is it to fly with an airline? Statistically you must make one flight every day for more than 8000 years to experience a hull loss accident. You are more likely to be struck by lightning; this is the safest way to travel.

Slide 5

In the late 1950’s we had 30-40 hull losses per million departures. In 2015 we had 0.32 hull losses per million departures. Initially, technical advances contributed to most of the improvements. Since the 1970’s, better ways to manage human error continued this improvement trend.

Slide 6

Human error remains the main threat. Today more than 80% of all accidents have human error as a direct cause or contributing factor.

In 1977, a collision between KLM and PanAm at Tenerife killed 583 people. How the experienced KLM captain did not listen sufficiently to concerns from his crew became a wakeup call.

Slide 7

A system relying only on one person was too fragile so we installed new principles and training using multiple redundant humans more as safety barriers. We sometimes say that the myth of the infallible captain died at Tenerife. We had to move from superior captains to a more team based approach. We established training programs to improved team performance, listening skills, decision-making and most of all; a mindset that accepts the reality of human error. The acceptance of human error is one of the most important ingredients in today’s low accident rate.

We called this training Crew Resource Management (CRM). Shipping, hospitals and other industries have successfully established similar programs.

In the 1990s we started focusing on making procedures more user-friendly. Concerns about complexity was not new, let me take you back to my first days in aviation. Use experience – not checklists, was an unwritten rule I quickly learned as a young airline pilot. Older colleagues had experienced having to choose between good airmanship and checklists. Since voice recorders monitored us, we always read the checklists but fast and superficial. Today, pilots do not read the checklist fast because they have to but carefully because they want to. What has changed?

Slide 8

In 1988, I woke up when Delta Airlines crashed close to my home in Texas. The pilots forgot the flaps and the warning horn failed. The voice recorder showed superficial checklist reading. They answered what they expected to see and not the actual indication.

Every pilot knows they need flaps and lack of knowledge was therefore not a problem. Typical airline checklists had many non-critical items; pilots perceived them as a nuisance and often read them too fast. The accident investigators did not just blame the pilot’s checklist discipline they also found system deficiencies.

Slide 9

Ten years later, Swissair had a fire in the video entertainment system. Faced with heat and smoke, the pilots still circled and read the complex checklists. This took too long; they crashed and lost all onboard.

What did we learn? Unnecessary complex checklists competes with common sense and experience. We made the checklist shorter. If unable to control the smoke or fire the pilots were quickly led to the conclusion – to land as soon as possible. This might have saved Swissair’s passenger and crew.

Slide 10

We studied how technological user-interface had improved while procedures complexity was getting worse. We had been copying in what we though was legal requirements. The checklists were designed more to pass audits than to achieve the goals of the regulations. Our new vision was more goal based with a tight focus on risk through concise simplicity. Checklists should not compensate for lack of experience or basic knowledge but for the fact that even the best can make mistakes.

Slide 11

We only permitted “killer items” in the checklists based on (1) no interference with tasks and (2) risk assessment (3) legal requirements. When studying the legal requirements we realized that the complexity was self-induced and not driven by the authorities.

We had two aviation revolutions. The first was acceptance of human error and the need for checklists. The second was respect for competence through simplicity and concise text.

Slide 12

The dialogue changed from checklists or not to the difference between poor and good checklists. The first step is to define objectives. The next is to make a measurable standard for checklist design. The last is to train subject experts to write.

Other industries have similar problems with complexity. Shipping is one of them. We see the principles applied to all aspects from navigation, to deck, engine, tankers, cruise ship procedures for food and medical issues as well as emergency response.

Slide 13

We see the principles used in industries like rail, oil, hospitals, manufacturing and deep sea diving. A recent article in the International Marine Contractons Association (IMCA) magazine tells the story of how Technip is using simplicity in text to improve safety.

Slide 14

Let us leave these specific cases and talk general - where does this complexity come from? Why do we have it?

A typical accident report often blame human error, saying that the knowledge was there but not used. The conclusion typically uses words like “procedure not followed”. But procedure not followed is seldom the root cause. Procedure not followed, is just a symptom. Digging deeper we find that that the root cause is that the company have no standards for making user-friendly procedures. Some say this was necessary for various reasons, that it was strategy they had to follow. To me it is the opposite; it is often a result of no strategy.

Slide 15

It is the result of different people making continuous modification without looking at the big picture. We end up with what I call spaghetti text where we are mixing overall goals written in a legal style with execution in the form of clear tasks written in a doable way.

Slide 16

The solution is to untangle this spaghetti and cut it into bite sized digestible pieces. We call this chunking – a well-known pedagogical principle.

Slide 17

Oil and shipping companies have established successful projects to untangled complex spaghetti manuals. Here is an example of an oil field manual used by arriving and departing ships. It is a 50-page document. The different colors are different types of information that we best understand if we read together and preferably, in the order we would do the job.

Slide 18

Statoil, Teekay and KNOT Offshore Tankers ran a project where they separated and reorganized text into process oriented step-by-step procedures following the normal flow of doing a job.

Slide 19

In 2014, Teekay’s navigation procedures had just below 49000 words they simplified it down to just above 17000 words. That is a 65 % reduction, but reducing words was not the goal, the goal was to be precise like the traditional 80 sign. This is now in use on over 200 vessels. Bernhardt Schulte Ship Management (BSM) did the same on 600 vessels BSM managed.

Slide 20

Less can be more is a popular saying – but only true if you take out the right things.

We need to make things as simple as possible but not anymore. Consequently, I prefer to say less can be more because you need to know what you are doing.

Slide 21

I used several years to make what I called a text-washing process. I made seven rules, which are easy to understand. Training people to use the methods turned out to be harder than I expected. What seemed easy took a bit of time to master– regardless of the writer’s background. But with old habits out of the way and some practice, most could write better and faster. This was a one-time investment

One of the seven rules was to reduce passive text. A passive text reflects a passive mind. Since most companies strive to be proactive it makes sense to use a proactive writing style in their SMS.

Slide 22

Here is an example: We removed filler words and double talk and focused even more on the killer items. This text is concise – saying what needs to be said clearly with as few words as possible.

In my opinion, the best way to get respect is to show respect. If we want people to respect our procedures then we should write them with a high respect for the competence of our people and the time pressure they often operate under. I believe there is a clear link between how user-friendly something is to how much it will be used. In other words – I believe that user-friendly procedures improves compliance.

Slide 23

More and more high reliability organizations see the need for a strategy using simplicity to improve safety as we can see in this case study video. https://www.youtube.com/watch?v=VLPQ6yE3fSE

Slide 24

Let me share another example from hospitals. They used aviation principles to reduce surgical complication rates by 42%. This number is documented through several studies in various parts of the world. But one problem remains, we only get these results among the doctors that use the checklists. This increased the focus on usability. I am currently working with a university hospital helping them improve text-washing procedures. The results are promising but teaching people text washing is a challenge.

Slide 25

When training people we first teach the concepts in three steps: (1) separate, (2) organize and (3) text-wash. People grasp the concepts quickly but need a fair amount of training before they master the methods. You may have heard the expression” if I had more time I would have written a shorter letter”. This implies that it takes more time to write concise. My goal is to teach people to write sort fast and for this to be second nature just like changing gears in your car. Because if it takes too long time to write concise then the old complex text will creep back in.

Slide 26

I believe using simplicity as a strategy can improve safety and prevent losses. Even though I have worked with it for many years, I feel I have just started a journey into the unknown. The insurance industry have a lot of experience with loss prevention and I hope you will join the expedition.