Preconditions to Unsafe Acts

Let us now climb higher on the ladder of Accident Causation "Food Chain" - Preconditions to Unsafe Acts - The conditions that make any human more prone to errors.

Preconditions for Unsafe Acts. Arguably, the unsafe acts of pilots can be directly linked to nearly 80% of all aviation accidents. However, simply focusing on unsafe acts is like focusing on a fever without understanding the underlying disease causing it. Thus, investigators must dig deeper into why the unsafe acts took place. As a first step, two major subdivisions of unsafe aircrew conditions were developed: substandard conditions of operators and the substandard practices they commit.

 

Substandard Conditions of Operators			Substandard Practices of Operators
Adverse Mental States	Adverse Psychological States	Physical/Mental Limitations	Crew Resource Mismanagement	Personal Readiness
Channelised attention	Impaired psychological state	Insufficient reaction time	Failed to back up	Excessive physical training
Complacency	Medical illness	Visual limitation	Failed to coordinate/ communicate	Self medication
Distraction Mental Fatigue	Psychological incapacitation	Incompatible intelligence/Aptitude	Failed to conduct adequate brief	Violation of crew rest requirements
Get-home-itis	Physical Fatigue	Incompatible physical capability	Failed to use all available resources	Violation of bottle to throttle requirements
Haste			Failure of leadership
Loss of situational awareness			Misinterpretation of traffic calls
Misplaced Motivation
Task Saturation

Substandard Conditions of Operators

Adverse mental states. Being prepared mentally is critical in nearly every endeavour, but perhaps even more so in aviation. As such, the category of Adverse Mental States was created to account for those mental conditions that affect performance. Principal among these are the loss of situational awareness, task fixation, distraction, and mental fatigue due to sleep loss or other stressors. Also included in this category are personality traits and pernicious attitudes such as overconfidence, complacency, and misplaced motivation.

Predictably, if an individual is mentally tired for whatever reason, the likelihood increase that an error will occur. In a similar fashion, overconfidence and other pernicious attitudes such as arrogance and impulsivity will influence the likelihood that a violation will be committed. Clearly then, any framework of human error must account for pre-existing adverse mental states in the causal chain of events.

Adverse physiological states. The second category, adverse physiological states, refers to those medical or physiological conditions that preclude safe operations. Particularly important to aviation are such conditions as visual illusions and spatial disorientation as described earlier, as well as physical fatigue, and the myriad of pharmacological and medical abnormalities known to affect performance.

The effects of visual illusions and spatial disorientation are well known to most aviators. However, less well known to aviators, and often overlooked are the effects on cockpit performance of simply being ill. Nearly all of us have gone to work ill, dosed with over-the-counter medications, and have generally performed well. Consider however, the pilot suffering from the common head cold. Unfortunately, most aviators view a head cold as only a minor inconvenience that can be easily  remedied using over-the counter antihistamines, acetaminophen, and other non-prescription pharmaceuticals. In fact, when confronted with a stuffy nose, aviators typically are only concerned with the effects of a painful sinus block as cabin altitude changes. Then again, it is not the overt symptoms that local flight surgeons are concerned with. Rather, it is the accompanying inner ear infection and the increased likelihood of spatial disorientation when entering instrument meteorological conditions that is alarming - not to mention the side-effects of antihistamines, fatigue, and sleep loss on pilot decision-making. Therefore, it is incumbent upon any safety professional to account for these sometimes subtle medical conditions within the causal chain of events.

Physical/Mental Limitations. The third, and final, substandard condition involves individual physical/mental limitations. Specifically, this category refers to those instances when mission requirements exceed the capabilities of the individual at the controls. For example, the human visual system is severely limited at night; yet, like driving a car, drivers do not necessarily slow down or take additional precautions. In aviation, while slowing down isn’t always an option, paying additional attention to basic flight instruments and increasing one’s vigilance will often increase the safety margin. Unfortunately, when precautions are not taken, the result can be catastrophic, as pilots will often fail to see other aircraft, obstacles, or power lines due to the size or contrast of the object in the visual field.

Similarly, there are occasions when the time required to complete a task or manoeuvre exceeds an individual’s capacity. Individuals vary widely in their ability to process and respond to information. Nevertheless, good pilots are typically noted for their ability to respond quickly and accurately. It is well documented, however, that if individuals are required to respond quickly (i.e., less time is available to consider all the possibilities or choices thoroughly), the probability of making an error goes up markedly.

Consequently, it should be no surprise that when faced with the need for rapid processing and reaction times, as is the case in most aviation emergencies, all forms of error would be exacerbated. In addition to the basic sensory and information processing limitations described above, there are at least two additional instances of physical/mental limitations that need to be addressed, albeit they are often overlooked by most safety professionals. These limitations involve individuals who simply are not compatible with aviation, because they are either unsuited physically or do not possess the aptitude to fly. For example, some individuals simply don’t have the physical strength to operate in the potentially high-G environment of aviation, or for anthropometric reasons, simply have difficulty reaching the controls. In other words, cockpits have traditionally not been designed with all shapes, sizes, and physical abilities in mind. Likewise, not everyone has the mental ability or aptitude for flying aircraft. Just as not all of us can be concert pianists or NFL linebackers, not everyone has the innate ability to pilot an aircraft – a vocation that requires the unique ability to make decisions quickly and respond accurately in life threatening situations. The difficult task for the safety professional is identifying whether aptitude might have contributed to the accident causal sequence.

Substandard Practices of Operators

Clearly then, numerous substandard conditions of operators can, and do, lead to the commission of unsafe acts. Nevertheless, there are a number of things that we do to ourselves that set up these substandard conditions. Generally speaking, the substandard practices of operators can be summed up in two categories: crew resource mismanagement and personal readiness.

Crew Resource Mismanagement. Good communication skills and team coordination have been the mantra of industrial/organizational and personnel psychology for decades. Not surprising then, crew resource management has been a cornerstone of aviation for the last few decades (Helmreich & Foushee, 1993). As a result, the category of crew resource mismanagement was created to account for occurrences of poor coordination among personnel. Within the context of aviation, this includes coordination both within and between aircraft with air traffic control facilities and maintenance control, as well as with facility and other support personnel as necessary. But aircrew coordination does not stop with the aircrew in flight. It also includes coordination before and after the flight with the brief and debrief of the aircrew. It is not difficult to envision a scenario where the lack of crew coordination has led to confusion and poor decision making in the cockpit, resulting in an accident. In fact, aviation accident databases are replete with instances of poor coordination among aircrew. One of the more tragic examples was the crash of a civilian airliner at night in the Florida Everglades in 1972 as the crew was busily trying to troubleshoot what amounted to a burnt out indicator light. Unfortunately, no one in the cockpit was monitoring the aircraft’s altitude as the altitude hold was inadvertently disconnected. Ideally, the crew would have coordinated the trouble-shooting task ensuring that at least one crew member was monitoring basic flight instruments and “flying” the aircraft. Tragically, this was not the case, as they entered a slow, unrecognized, descent into the everglades resulting in numerous fatalities.

Personal Readiness. In aviation, or for that matter in any occupational setting, individuals are expected to show up for work ready to perform at optimal levels. Nevertheless, in aviation as in other professions, personal readiness failures occur when individuals fail to prepare physically or mentally for duty. For instance, violations of crew rest requirements, bottle-to-brief rules, and self-medicating all will affect performance on the job and are particularly detrimental in the aircraft. It is not hard to imagine that, when individuals violate crew rest requirements, they run the risk of mental fatigue and other adverse mental states, which ultimately lead to errors and accidents. Note however, that violations that affect personal readiness are not considered “unsafe act, violation” since they typically do not happen in the cockpit, nor are they necessarily active failures with direct and immediate consequences.

Still, not all personal readiness failures occur as a result of violations of governing rules or regulations. For example, running 10 miles before piloting an aircraft may not be against any existing regulations, yet it may impair the physical and mental capabilities of the individual enough to degrade performance and elicit unsafe acts. Likewise, the traditional “candy bar and coke” lunch of the modern businessman may sound good but may not be sufficient to sustain performance in the rigorous environment of aviation. While there may be no rules governing such behaviour, pilots must use good judgment when deciding whether they are “fit” to fly an aircraft.

Next week we will progress into the next level of accident causation food chain - The Supervision.

Until then,

The Erring Human.

Andersen's Temple of Doom

 “We just received a message from Saddam Hussein. The good news is that he’s willing to have his nuclear, biological and chemical weapons counted. The bad news is he wants Arthur Andersen to do it.”                                 

  -George W. Bush, 2002

Salient points that emerge from the case study are:

1.        Policies.       Andersen tried to present a defense that destruction of documents was in accordance with its “Document retention policy”. However, the courts were not impressed because while policies are common in business and it is not illegal for a manager to instruct his employees to comply with a valid document retention policy under ordinary circumstances, policies must be reasonable and evenly applied. In this case, it was seen that the policy was selectively applied only to Enron documents!

2.       Role of Supervision.         The decision to destroy documents started with Temple, but its implementation was company-wide. No one questioned, much less opposed, Temple’s instructions. Over a dozen of Andersen’s most senior global managers were party to discussions in which pursuit of the mostly ignored document policy was urged, and dozens more of the firm’s lower level employees carried out the work of purging the record, without objection. The document destruction was not limited to Andersen’s Houston office; Enron records were also destroyed in Chicago, Portland, and London.

3.       Corporate Culture.           Andersen’s in-house lawyers were expected to “rubber-stamp” all transactions, regardless of ethical or legal propriety. Andersen seemingly expected its employees, including in-house counsel, to protect the “firm” and its clients at all costs, legal or otherwise. Andersen had an “up or out” environment, in which employees either moved up the ranks or were moved out of the firm. By the late 1990s, the sure and possibly only way for Andersen employees to move up the ranks was “to keep both their bosses and the people at Enron happy” and the sure way was to approve every transaction. By contrast, the sure way for Andersen employees to move out of the firm was to dissent to an Enron transaction.

The experience of Andersen partner Carl Bass exemplifies the “yes-man” culture at Andersen. Bass was a senior partner in Andersen’s Houston office. He served on the prestigious “Professional Standards Group (PSG)”, an internal team of accounting experts that reviewed and approved troublesome “accounting issues” confronting local offices. For decades, the PSG’s word was accepted as law at Andersen.

Enron was considered one of Andersen’s highest-risk clients. In February 2001, Bass, who had been assigned “to monitor . . . high-risk audit[s], strongly objected to Enron’s accounting.”  Bass’s objection was overruled by local partners in the Houston office; Andersen was the only Big Five accounting firm that allowed local partners to overrule the PSG. Thereafter, Bass continued to object to Enron’s accounting and, not surprisingly, tensions grew between Bass and Enron. Enron “considered him a roadblock to their rapid fire deal-making.” Rather than stand up for Bass – a member of the PSG – Andersen, in an unprecedented move that was protested by most of the members of the PSG, demoted Bass by removing him from all oversight of the Enron account. Bass was demoted for being too rules-oriented. The demotion was no small matter, as it was approved by Andersen’s CEO Joe Berardino.

Bass paid the price for saying “no” to a rogue client. At least two other Andersen accountants – Jennifer Stevenson and Pattie Grutzmacher – were also removed from the Enron engagement for challenging Enron’s use of SPEs.  Undoubtedly, these demotions sent a clear message to all Andersen employees, including Temple.

In this environment, how could one expect Nancy Temple, a relatively junior in-house lawyer who had recently been assigned to the Enron account, to say “no” to Enron or senior Andersen partners when she had recently witnessed the demotion of a senior partner for the very same act? Thus, Andersen’s culture presented Temple with an excruciating dilemma: protect Andersen by instructing its employees to destroy Enron’s documents or destroy her career. Unfortunately, she chose the former and, ironically, destroyed Andersen.

4.       The Temple of Doom.      In conclusion, Andersen’s “Temple of Doom” was its corporate culture, a cult-like culture in which employees were not free to think or act independently. It was this culture – and not greedy partners or unethical lawyers – that doomed Andersen to a needless death.

So, what do we learn from this case study?

This case study is a reaffirmation of the earlier statement that Organizations create a climate in which humans work and take decisions. The climate, or culture, created by an organization has a direct bearing on the type of decisions its employees take, and hence the number of errors they make!

The role of supervision is also clearly brought out here. Any degree of supervision over Temple could have prevented this disaster. However, those responsible for supervising Temple went along with her…but we will talk more about this when we discuss the role of supervision in detail.

So, next week we will move on to the higher elements in the error causation food chain.

Until next week,

The Erring Human.