SAFETY
things, we are often fatigued not because of how long we worked on the job but because of what we do outside of work. The real issue might be how long a commute someone has or whether or not they are getting enough sleep. We might skip the written documentation not because we are lazy but because we honestly think we know what it says. We never imagine when distracted that it will end with, “Where did I put that tool?” We don’t know we forgot something BECAUSE WE FORGOT IT! I once worked with a pilot who lit off the engine in his Jet Ranger with the blades tied down. He never wanted to do that again, so he put a white sock on his cyclic stick post flight so it would remind him to untie the blades if he hadn’t done so. This worked for him for a while, and then he did it again, with the sock in place. A good pre-flight using a checklist is what he really needed to do.
THE SIX EMOTIONAL STATES We use the “Dirty Dozen” as convenient labels for what causes errors, but I think what is behind these labels is where we need to be looking. You probably know of the “seven deadly sins” which are pride, envy, anger, greed, laziness, gluttony and lust. I’m going to borrow them out of context and drop gluttony, lust, anger and greed for this discussion, but I’ll add forgetfulness, deceit and fear. Instead of the seven deadly sins we now have the six sometimes-good, sometimes-bad emotional states: pride, envy, laziness, fear, deceit and forgetfulness. We can control these pretty well except for forgetfulness. In my mind, these are the root causes behind the “Dirty Dozen.” They are the things that allow us to make the choices such as, “I can skip that step in the procedure,” or, “No time for
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the written checklist, I know it by heart.” The weird part is that some of these can strengthen our ability to produce a safe product or they can work against us. You can be proud of your work (good) or you can have false pride (bad) and think your work is better than it really is. 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 muffler, 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 five?). Having been an inspector, I understand why, when called on to inspect a job, it was more common than I’d previously thought to find something wrong. I believe if our jobs were reversed, the person who would be looking at my work would probably fill the job of inspector as
well as me and find 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 find 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 find 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 from the top management all the way to the cockpit, the same way the development of cockpit resource management (CRM) was not going to happen just because some pilots liked the idea.
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