A coworker once told me about his uncle who had a
variety of gasoline-powered yard tools. After each use he’d remove and clean the spark plug, drain the gas, re-paint the muffl er, lube wheels and cable controls and so on. Who in their right mind would do this? His uncle’s attitude was, “Who wouldn’t do these things to assure they would operate as they should the next time he needed them?” He was proud that his tools started when he went to use them. My tools don’t always cooperate but I just can’t bring myself to spend the time doing what this fella did. Who is right? The Carlin quote is so obvious that it hurts. How can
we not take all the time we need to make sure we turn out a product that is as safe as possible? Do we ever take all possible steps to ensure safety? Where do we draw the line? Anyone who has spent years maintaining aircraft has made a mistake of omission, forgotten or been distracted from completing a task, failed to use the documentation, thought they knew better or were too embarrassed to ask a question. A small step like not calling on a co-worker to check your work is easy to skip because it saves time. Why have someone check to see that you’ve put in four cotter keys (or was it fi ve?). Having been an inspector, I understand why, when called on to inspect a job, it was more common than I’d previously thought to fi nd something wrong. I believe if our jobs were reversed, the person who would be looking at my work would probably fi ll the job of inspector as well as me and fi nd the same sort of discrepancies. I believe it’s similar to why we often remember something when we stop thinking about it. The person in the inspector role knows their job is to fi nd things and is not wrapped up in the detail of performing the task; only how what can be seen and documented conforms to what it should look like. We know it isn’t wise to inspect our own work but don’t spend too much time thinking about why that is a truism or what we would need to do to make that less of an issue. In a “perfect” world, inspectors would fi nd nothing needing additional attention. We tend to believe that having one additional set of eyes is enough for most QA functions. Is this ever wrong? Of course it is. This fact helps us also understand that paying attention to detail, although a very large part of the safety equation, will not eliminate serious errors; that it does is another myth often repeated in safety management. Death and destruction can still happen when the best safety system possible is in place because somebody was busy sending a text message while driving the train. The sterile cockpit concept was implemented by the airline industry because of this sort of scenario. The airlines required a “cultural” change because it was clear that to a large extent, individuals were not capable of paying attention to detail without an industry-wide push and creation of universally-accepted policy with the understanding that there were consequences if it was not followed strictly. That cultural change had to be initiated and enforced
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