Close Calls: Managing Risk and Resilience in Airline Flight Safety PDF
Preview Close Calls: Managing Risk and Resilience in Airline Flight Safety
Close Calls This page intentionally left blank Close Calls Managing Risk and Resilience in Airline Flight Safety By Carl Macrae © Carl Macrae 2014 Foreword © Jim Reason 2014 Softcover reprint of the hardcover 1st edition 2014 All rights reserved. No reproduction, copy or transmission of this publication may be made without written permission. No portion of this publication may be reproduced, copied or transmitted save with written permission or in accordance with the provisions of the Copyright, Designs and Patents Act 1988, or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, Saffron House, 6–10 Kirby Street, London EC1N 8TS. Any person who does any unauthorized act in relation to this publication may be liable to criminal prosecution and civil claims for damages. The author has asserted his right to be identified as the author of this work in accordance with the Copyright, Designs and Patents Act 1988. First published 2014 by PALGRAVE MACMILLAN Palgrave Macmillan in the UK is an imprint of Macmillan Publishers Limited, registered in England, company number 785998, of Houndmills, Basingstoke, Hampshire RG21 6XS. Palgrave Macmillan in the US is a division of St Martin’s Press LLC, 175 Fifth Avenue, New York, NY 10010. Palgrave Macmillan is the global academic imprint of the above companies and has companies and representatives throughout the world. Palgrave® and Macmillan® are registered trademarks in the United States, the United Kingdom, Europe and other countries. ISBN 978-1-349-30632-9 ISBN 978-1-137-37612-1 (eBook) DOI 10.1007/978-1-137-37612-1 This book is printed on paper suitable for recycling and made from fully managed and sustained forest sources. Logging, pulping and manufacturing processes are expected to conform to the environmental regulations of the country of origin. A catalogue record for this book is available from the British Library. A catalogue record for this book is available from the Library of Congress. Typeset by MPS Limited, Chennai, India. Contents Foreword by Jim Reason vii Preface ix 1 Searching for Risk and Resilience 1 Making sense of safety 4 Bracketing the problem 9 Organisations, risk and knowledge 11 A bird’s eye view 22 2 Airlines, Incidents and Investigators 25 Vignettes of incidents in the field (and the air) 28 Organising airline flight safety 40 The work of flight safety investigators 50 3 Understanding and Interpreting Safety 57 Safety-critical assumptions 59 Concepts of organisational safety 67 Practical theories of safety and risk 74 4 Analysing and Assessing Risk 89 Qualities of resilient practice 90 Assessing organisational risk resilience 104 5 Overseeing and Monitoring Safety 114 The work of safety oversight 115 The challenges and risks of knowledge 128 6 Identifying and Constructing Risks 138 A vigilant approach to interpretive work 139 Producing and using suspicion and doubt 149 7 Improving and Evaluating Safety 165 The nature of oversight and improvement 166 Creating networks of participation around risks 172 Appraising the value of safety improvement 186 8 Organising Resilience 192 Practical sources of safety 196 Organisational proximity and diagnosis 199 Ignorance and early warnings 201 v vi Contents Disruptions and epistemic work 205 Rethinking resilience and high reliability 208 Coda 214 References 216 Index 223 Foreword I am delighted to be given the opportunity to write this Foreword. Furthermore, I do so with some measure of pride. Carl Macrae chose to be an undergraduate student of psychology during my time teaching at the University of Manchester. Indeed, he was my tutorial student during his first and final years. I remember writing at the bottom of one of his early essays: ‘More psychology, Carl, and less philosophy, please’. Fortunately that did not constrain his talents, as this book goes to show. Safety science is one of the toughest games in town. Unlike the natu- ral sciences, it is not enough for an idea to be read, quoted and tested. It has to work in practice as well. There are not enough trees in the rainforest to write a set of procedures that will guarantee freedom from harm. To progress in this most difficult of areas needs a subtle combina- tion of modern psychology, human factors and a deep understanding of the philosophy of technology. In my view, Carl’s discussion of the nature of safety is one of the best I have ever read. And I have spent a professional lifetime trying to unravel its complexities. A large part of my work has examined the nature of error and risk in safety critical systems, and yet I have always had difficulty with the mean- ing of the term ‘risk’. That it is said to be a function of both likelihood and severity has never been entirely satisfactory. The argument that runs through this book that interrelates risk, safety and resilience – what Carl terms ‘risk resilience’ – clarified my thinking. I had a true ‘Aha’ feeling when reading this. Risk resilience is about an organisation’s ability to protect its operations from the potential of minor mishaps combining into major catastrophes. In short, it is about the effectiveness of the prac- tices that produce defences, barriers and safeguards rather than about the actual or predicted outcomes of reported (and usually minor) events. This is an observation of major theoretical and practical importance. The main thrust of this book is to elucidate the processes and prac- tices by which the risks of airline flight safety incidents are understood, identified and acted upon by very experienced flight safety investiga- tors. These practices are analysed with regard to three important and innovative organisational concepts: risk resilience, interpretive vigilance and participative networks. These concepts are grounded in richly detailed data from an in-depth ethnographic study of the work that vii viii Foreword is actually done in airlines to analyse safety and manage risk or, more precisely, ‘risk resilience’. I have long argued for the importance of understanding the practical contexts and conditions in which people work, and this book wonder- fully exemplifies and extends that idea. It demonstrates the value of closely analysing the practical work of safety management, and the important and practical insights that can result. This is an area with which I am well acquainted; nonetheless, the insightful and original exposition developed in this book cast fresh light for me upon familiar ground. I confidently predict that this work will have a major impact upon the way safety professionals and academics think and do research. This impact should be felt particularly in healthcare, where Carl is cur- rently focusing much of his efforts and where there remains so much work to do. No doubt we have all experienced the ‘I-wish-I-had-written-that’ feeling. I certainly felt it many times when reading this. It is a joy to read something that I wish I could have written. Especially when the writer was once my student, and amongst the best of them. Would he have been so good had he not been a Manchester psychology graduate? Almost certainly, yes. But he may have exercised his talents in some other less demanding (but more professionally appreciated) domain, such as experimental psychology – if you can control the variables, it has to be trivial. But that’s my personal prejudice after having been an academic psychologist for nigh on forty years. Jim Reason Professor, Department of Psychology University of Manchester Preface As I type this sentence I am sat sipping a glass of wine while watching a beautiful sunset of mauve and umber, waiting for dinner to be served before settling down a little later to watch a movie. A small screen tells me that, although I would not know it, the temperature outside is a brisk fifty two degrees below freezing and I am travelling at nearly nine hundred kilometres an hour, suspended ten kilometres above the Earth. Outside, a few centimetres to my right, there is so little oxygen that I would pass out in seconds. But the only indication of any of this is a slight tremor on the surface of my drink and the low rumble of the four giant turbofans that are propelling me at such startling speeds across the sky. The experience of modern aviation is now so commonplace that its most remarkable feats pass unnoticed, a mere interruption – and usu- ally a discomfort – in our busy daily lives. Mass travel on the lower edge of the stratosphere at speeds close to the speed of sound seems normal, routine, simple, even. Yet it is anything but. This single aircraft is made of millions of individual components that must all work in perfect harmony for the next eleven and a half hours. This single flight is the result of the coordinated efforts of not just the crew onboard, but of thousands of individuals. Many of those individuals are charged with thinking about one thing only: flight safety. This book is about one particular breed of those safety professionals – airline flight safety investigators, and the ways they see and make sense of the complex, ambiguous world they inhabit. Aviation stands out amongst modern industries for its scale and complexity, its deep preoccupation with reliability and its sophisticated infrastructure for improving and enhancing safety. This is an industry in which one major airframe manufacturer has been known to boast that their airliners achieve on-time departure reliability of 99.67% – compared to their competitor’s presumably woeful 99.35%. This is also an industry renowned for routinely achieving seemingly astonishing levels of safety. In 2012 fatal airline accidents occurred at the lowest rate since the dawn of the jet age. Nearly forty million flights resulted in just 21 fatal accidents. Yet even that statistic was greeted in the industry as a sign that they might just have been lucky and must try harder next time. The timeless quote of Alfred G. Lamplugh, an aviation insurer speaking in 1931, is still found on the walls of airline offices around the world ix
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