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> I, too worship at the altar of the Great Ones like Bob and
>Frank - but I take different approach, and for good reason. I believe that
>many - perhaps most - aviators are chronic underachievers. That is to say,
>they will not independently seek higher standards unless at the point of a
>gun. (This is probably based upon experience although I claim it from
>observation! ;-]) I maintain that the PURSUIT of perfection - error
>elimination - should be the standard. To say that there will always be human
>error in the cockpit leads, I believe to a tolerance factor in individuals
>that is counterproductive, especially when it is related to the drive for
>personal improvement and accountability.
The aim for zero error is the Skinnerian model (stimulus-response), while
goal driven error correcting behaviour is the percetual control theory
model (I think many have read my views on these two positions before). For
humans never to make errors they must always perceive the objective truth
of a situation (this doesn't happen, remember the existence of illusions),
they must always have the strictly correct action to all situations
programmed into memory with perfect retrieval always possible (this doesn't
happen - read the literature on memory, memory retrieval, mental models)
and they must always be attending to all salient cues in the environment
(this doesn't happen - relevant literature includes that on workload,
attention, vigilance). That doesn't seem encouraging for the zero error
view of the world. I do not believe that the accident data base supports
this under-achiever view of the aviator at all. If I have $100 to spend I
would rather spend it in those areas that have the greatest potential
payoff and I believe training in the area of time, attention and knowledge
management is that area.
>While it may be true that all error will never be eliminated, I feel greater
>gain can be achieved by moving INDIVIDUALS towards higher standards - fewer
>errors - with the goal of perfection. Perfection doesn't necessarily mean
>"forever" - that's too long for anyone to comprehend - BUT I as a crewmember
>can seek perfection for the next five minutes or for the next flight, or for
>the next week or month. Like they say in alcoholics anonymous "one day at a
>time." That is my training perspective - expect perfection - and be
>disappointed (but not to a debilitating state) when you don't achieve it.
>Good individuals make better teams.
Indeed the position that good teams start with the highest levels of
individual skills is a position, based on theory, that we have put in
writing over the last year or so. Interestingly the recent material on
communication pros and cons (refered to in a post from Vince Mancuso) is
absolutely consistent with, and predictable from, this theoretical position
- based on the IP/PCT model (I wrote about this in an article published in
RAAF Safety Spotlight last year. Perhaps Neil would consider posting this
article on the web site if there is enough interest.
>Second concern - the semantics of "generational CRM." Supposedly, we are
>now
>in the midst of "fifth-generation CRM." This somehow connotes that all that
>has come before has been overcome by a newer and "better way." I disagree.
>New does not automatically mean "better." The fundamentals of hazardous
>attitudes and subtle incapacitation that I saw in my very first exposure to
>CRM in the early 1980s are still among the most valuable tools in my human
>factors kit bag today.
I guess the success of previous generations of CRM is a moot point. I
think the move from generation to generation was at least partly driven by
the perception that not all things were right in the state of Denmark.
Anyway each generation of CRM was built on the base of what went before. I
suspect you would have to be very brave to promote a first generation
programme to managment these days. But if you have the faith...
>Finally, it is my gut feeling that error management is deals primarily with
>the "bottom feeders" (I know that will generate some hate mail) - i.e. "How
>can we take crews performing at marginal levels and keep them from killing
>themselves and others?" Because we are limited in resources (can't train
>both
>the high and low ends of the performance spectrum) - and are interested first
>and foremost in safety - this is a necessity - but it takes away from seeking
>and achieving higher standards of performance. The entire American education
>system is in disarray due to the two decade focus on the low achiever. We
>should not repeat this mistake. High achievers raise the level of all around
>them. We must not forget this fact or lose this leverage.
Even surface feeders screw up (but then IP/PCT would tell us that ;-).
Look at all the innane statements made by those supposedly at the top of
the heap over the years...remember a leading scientist stating that humans
couldn't fly, that human powered flight was impossible. Indeed look at our
own archives sometime (perhaps I haven't been able to convince everyone of
the absolute truth of the IP/PCT approach because I have been using a dry
fly rather than a wet fly - guess I will have to change my rig ;-)
>OK, OK, I'm calming down now - in reality I see the need for both
>approaches -
> organizational foci on risk mitigation and error management - and pushing or
>pulling high achievers to the next rung on the ladder to perfect
>performance. Unfortunately we seem to be pursuing only one.
I do believe, like Tony, that the critical contribution of individual skill
levels has been lost in much of the team work literature and past CRM
programmes. I have challenged the forums to justify the synergy position
on several occassions and remain unconvinced. While we have these mystical
ideas that putting two people together generates a magical multiplying
effect we are doomed to repeat the past. The article on communication that
Vince pointed us to rasied some of the problems in communication (critical
to team working) in a purely descriptive way. You can't really generalise
from the material in the article and any real condition will probably fit
more than one of their situations. We believe that at least some
prescriptive guidance can be derived from our theoretical position. At
least that is what we said in our report to the CC-130 community recently.
Cheers and all the best to all for Y2K-1 and the third millenium -2.
Keith Hendy
DCIEM
Toronto, CANADA
Keith Hendy
Systems Modelling Group
DCIEM
PO Box 2000
Toronto, ON M3M 3B9
CANADA
Ph: 416 635 2074