I recently spoke with the folks at FedEx about their mediated debrief
method of debriefing crews violated by the FAA. The concept has a great
appeal. As I understand it, the crew is not penalized with a violation on
their record if they submit to a lessons learned debriefing without fear of
retribution. Since the vast majority of FAA violations come as a result of
human factors errors this is a great way for the industry to spread the
word (via ASRS) on lessons learned. I am assuming that this is old news
for most of you but I am going somewhere with this.
And as the folks at UT have documented, it is essential to create an
organizational culture where human factors errors are acknowledged and
accepted as reality. Only by with this acknowledgment is it possible for
the organization's CRM program to work at its best. As a U.S. Air Force
pilot, I am somewhat protected by the USAF when it comes to violations. So
when (I do not mean any ill word of the USAF) a USAF pilot is met with an
event that includes a FAA violation or any other infraction (even the most
minor) there is usually disciplinary action taken (by the USAF not the FAA)
against the aircrew, sometimes harsh, sometimes not. So, as a result, when
an aircrew is not caught via a violation or some infraction, they are not
at all likely to come forward and tell their supervisors of their
experience so others may benefit.
This fear of retribution is understandable. However, after discussions
with some of my commanders, they seemed impressed with the way the mediated
debrief works in the civil sector. I asked them if they thought it logical
that we have a human factors program that stressed the need for everyday
vigilance in mitigating human error and yet did not facilitate a proper
environment or vehicle to acknowledge that crews tend to fall into HF traps
almost on a daily basis. It is often up to the rest of us to wonder why so
and so's crew is on the boss's carpet, and then they usually come out
either not wanting to talk about the infraction or giving a watered down
version of it because they have been punished as such. My bosses are in
somewhat of an agreement that they would much rather something positive
(lessons learned) come of an infraction but we do not have a program or
method to debrief the human factors induced infractions.
I am imagining something similar to the mediated debrief used by the civil
sector. Since the military has only limited and broad based anonymous
reporting systems, and generally does not participate in the ASRS, maybe we
need to research a way to bring everyday local human factors errors to the
forefront (beyond annual facilitated courses). We do offer protection
from punishment to crews involved in mishaps but do not for violations or
infractions of SOPs due to human factors. I am assuming this protection
must come first before crews start talking. I am of the opinion that
leadership must not only stand behind the CRM courseware, but also create
an environment that strives to learn from its own local human factors
lessons, not hide them. Do you think this culture, beside a good CRM
program, is essential in creating a proper organizational safety culture?
This would of course, necessitate a huge paradigm shift. Has anyone
undertaken something like this at the military or similar level? Am I
being realistic? I would appreciate any comments.
Thanks,
Capt Andy Newman, USAF
(I'll make my next one a lot shorter)