My appologies for not reading this sooner. In this message you state a
Boeing study showed "65%-150 out of 232 airliner accidents" were the result
of the belief it OK to not follow procedures. Do you know where I could
get a copy of this report?
Thanks
Shane
----------
> From: Doug Edwards <dougwds_at_b022.aone.net.au>
> To: CRM Network <crm-devel_at_db.erau.edu>
> Subject: Culture
> Date: Thursday, August 13, 1998 5:20 AM
>
>
> G'Day
>
> As a child, I was taught never to pick up a snake. Aaah! What the heck?
> Culture can't bite. 'Specially if you grab it by the back of the neck.
>
> A while back, Hidetake Sakuma raised the issue of flight crew behaviour
> under the terrible stress of a major emergency. He suggested that
> cooperative behaviours need not be attributable to crm alone. He later
> in the debate clarified his position, contrasting 'thoughtful (not
> necessarily heroic) behaviour' 'not producing any conflict' with
> 'compelling action to do a right thing'.
>
> That got me thinking about behaviour options and choices, especially
> when under pressure. I referred back to the University of Texas'
> Helmreich/Merrit work on culture. People from different cultures will
> allocate different 'weight' to the same 'pictures'. The example from
> that work that got some media play down here was 'trust' in the
> automatics, eg, letting the autopilot keep doing the job even when the
> crew is in doubt.
>
> The Helmreich/Merritt work described cultural characteristics that might
> be perfectly harmless - charming even - in walks of life where safety is
> not critical, but which, in a flight crew, will be most undesirable
> baggage. Cultural differences are not just of national origin ('macro').
> Where I work, you can easily 'sense' the different culture ('micro')
> from one training school to another, and between airlines. In air
> forces, the microculture within a transport squadron will differ
> markedly from that in a fighter unit. (Not taking sides, here, just
> observing.)
>
> No point thinking about this stuff if you can't draw useful conclusions,
> so I went back and read some CVR transcripts. Sure enough, there are
> plenty of instances of behaviour that could be described as defining
> 'the prevailing flight crew microculture' for those airlines. They
> include a preference for being laid back when there is genuine cause for
> alarm, acquiescence with inappropriate commercial pressure, and, worst
> of all, the complacent belief that it's OK not to follow procedures.
> (Boeing study, 65% 150 - out of 232 jet airliner accidents.)
>
> Still not getting anywhere, I'm given some assistance by a post from a
> Canadian pilot whose first language is not English, and a response by Dr
> Turney. Is there such a thing as a 'culture-free' zone? Well, my earlier
> thinking suggests that, if it can be done, if a culture-neutral place
> can be obtained, then the cockpit ought to have first priority for this
> development. If it can be done, it must be done. Now the crm (and other
> training) goal posts are just beginning to take shape.
>
> When you look at so many of the characteristics that constitute a
> microculture, they pretty much all are matters of choice. I can choose
> to be laid back, or I can prefer to be alert, even against my national
> background and personal predilictions. Even under stress, I can choose
> between domineering behaviour leading to unresolved conflict or I can
> act so as to promote cooperative problem-solving. The abject
> professionalism seen too often in CVR tapes can also be defined as a
> matter of personal selection from the range of options.
>
> Up to a point, I concede. As Oscar Quintero reminds us that
> understanding the mental models at work in managing attention and the
> process of focussing lies at the root of coming to grips with human
> error and judgement processes. If I do not do injury to your submission,
> Oscar, I think you are implying that training choices can be made that
> will advance the microculture in aviation away from where it now too
> often is towards real professionalism. 'Focussing', in decision-making,
> has been seen in so many accidents, where the dominant influence has
> been one person's obsessive tracking of the wrong goal. That's
> 'compelling action' of no use to anyone.
>
> But it's 'Pepehahns''s post that starts to bring the goal posts into
> clear focus. The time available to get the team cooperating, sharing
> joint objectives, motivated, happy with the methods to be used, a little
> hugging to dissipate negative tensions, might not be enough. 'Pull Up
> ..' 'Turn right!' The responsible decision maker has to act now
> regardless of grounds for conflict. 'What do you mean? Birds? I don't
> see any ...'
>
> But hang on, birds on short finals is the sort of emergency we train
> for, no? In a sense, the potential for conflict takes lower priority to
> the vital need for immediate action. We train so that the compelling
> action is the right one, and instantly operable by the whole crew, not
> just one of them. More important, we have assessed the situation,
> decided on proper responses -- in advance -- and thoroughly prepared our
> reactions so they can be instant and automatic. Indeed, we have
> checklists full of pre-ordained decisions.
>
> My least favourite CVR tapes are those that reveal total lack of basic
> preparation. On one tape you hear the letdown plate being referred to,
> late in the piece, the pages being turned just now, with the crew about
> to descend into an unfamiliar field. The time to become intimately
> familiar with that letdown plate was the night before, not just before
> descent! Lack of preparation leads to the sort of impromptu
> decision-making environment in which the pathogen -- obsessive focus on
> the compelling action -- flourishes.
>
> I wish now I hadn't gone back over those transcripts. There's another
> appalling quality displayed - imprecise, uninformative, use of language
> - meaning-deprived gibberish denying any real opportunity for either
> pilot to reveal his thinking and intentions and thus ensuring the other
> pilot has no chance to approve or disapprove, or assist and support. In
> these microcultures, even routine checklists have degenerated from
> precise, sharp, 'challenge and response' words to laid back, casual,
> 'Joe Cool', waffle.
>
> So there are the goal posts. The aeroplane can and should be rendered a
> 'culture-free' workplace. There are cultural attributes in flight crew
> that work against the interests of safety. They may be deeply
> entrenched, but must be neutralised. Regardless, they are largely
> matters of preference. That is, they can be over-ridden by personal
> choice, though it will be difficult. The training to enable that must
> therefore be (a) closely focussed, ie, just what is needed for aviation
> professionalism, no more, especially not whole-of-life behaviour
> modification, and (b) it must be rigorous, including absolute commitment
> to and practise of precise and meaningful language in all flight
> management communication along with deep learning of all critical
> checklist actions and greater effort in preparation for each and every
> flight. It's going to need serious application and self-discipline, but
> isn't that what being a professional is about?
>
> Finally, in my view, tough training such as this (it's commonplace
> enough in the military) is to be separated from crm exercises. The crm
> session is where the crew show how well they have used the other
> training to strengthen their participative behaviours.
>
> Cheers
>
> Doug