Man-Machine Systems Engineering: how humans relate to technology and each other

High Expectations

Since the dawn of aviation, the prevailing expectation was that better technology would equal lower accident rates. However, in the late 1970’s we noticed that although Aviation technology had improved dramatically, accident rates remained stubbornly resistant to change. We found that improved technology was solving problems while creating others.

Cockpit Confusion

For example, more automation in the cockpit led to new ways of managing the aircraft, often with unintended consequences. Each pilot in a modern “glass” cockpit has an FMS (Flight Management System) computer screen. Simply put, on autopilot inputs into the FMS control the speed, altitude, and flight path of the aircraft. “If” one pilot should make inputs into the FMS without notifying the other pilot, each pilot could have a different idea of the future vector of the aircraft. This has happened on many occasions because one pilot assumed the other knew what he was doing. FMS technology has changed the rules on how we communicate in the cockpit, always notifying and obtaining acknowledgment from the other pilot when changes are made in the FMS.

Wiener’s Law

Dr. Earl Wiener addressed the idea that humans faced new challenges each time the technology changed with one of his famous Wiener’s Laws: “Any time you solve a problem you create one. The best you can hope for is that the one you solved is of greater magnitude than the one your created.”

The Human Factor

Innovative research by Drs. Bob Helmreich, Earl Wiener, John Lauber, and Clay Foushee, among many others, led the airline industry to focus on the one element that had not changed: the human element. Thus, a school of thought regarding how pilots relate to each other and to
the technology and tools they use was born. At the time, studies showed that 60-70% of all airline accidents were caused by human error, primarily by flight crews.

Top Training

To reduce this statistic, every major US airline began training pilots
in Human Factor skills. A series of programs, focused upon the human element, became known as CRM (Crew Resource Management). These programs expanded rapidly to include anyone who had a “dog in the fight” as flight attendants, mechanics, and flight controllers/dispatchers were incorporated into the expanded team.

The Power of Teamwork

Today, such courses and the skills they teach are part of commercial airline operations world-wide. CRM is not the only change that we’ve implemented in cockpit protocol over the past 25 years but it has been a huge part of the change. From early statistics showing 60-70% of all commercial aviation accidents were caused by human factor breakdowns, this figure is now in the 50% range. Might not seem like much, but this is a huge improvement. CRM cannot take credit for all of this improvement but is certainly a large part of it.

Risky Business

CRM concepts have also spread to military and corporate flight operations; more recently, CRM has moved beyond aviation to other high-risk, team-centered environments such as hospitals, chemical
plants, and nuclear control rooms. In some high-risk hospital settings, we’ve seen improvements of 50-75% in error/accident metrics.

Plane Comforts

CRM has made a difference. In aviation, there are many success
stories. Accident rates have been reduced. “There are old pilots and
bold pilots but no old bold pilots.” Safety is a systems-oriented
concept that can only be achieved through excellent teamwork. As you
begin your next flight, take comfort in knowing your crew has been
trained for the technical and human aspects of their jobs.

Fly Safely.

Captain Alan W. Price

Photos from Flickr. Photo credit: The cockpit of the Enola Gay by ten safe frogs

Last month, Capt. Chesley “Sully” Sullenberger (a fine graduate of my alma mater, the USAF Academy) took a very courageous stand in his testimony before Congress following the “Miracle on the Hudson.”  Sully told of the worsening conditions in the airline industry in regard to compensation and retention. One of the most cogent comments he made was “I do not know a single pilot who would counsel their children to choose a profession in the airline industry.”  Let me relay my own story and relate it to the tapestry Sully weaves.

Four years ago, I retired several years early from a profession I loved and in which I had spent my entire working life.  The last 20 years of my career, I held increasing levels of responsibility and loved the people and challenges of the airline industry.  Early retirement for me was a very tough choice, but one made only for economic reasons…I fully expected my airline to declare chapter 11 (they did) and cancel my pension (they did). The pilots doing the same job today are making roughly 50% of what I did due to pay, benefit, and work rule changes. They are still making a decent living, but at a far lower rate than before. At my airline, over 1,500 very experienced captains took early retirement in the years preceding the bankruptcy, many seeking to preserve a portion of their pension by retiring early – a huge loss of experience and this at just one airline!

Reaching the pinnacle of an airline pilot’s career requires many years of preparation.  While gaining experience and ratings, pay and working conditions are sub-par.  The time and commitment required is akin to a doctor who finishes medical school and then spends many more years in specialty training. Then, when reaching the top of one’s career, the rules change and the economic model is completely rewritten.  This is the state of our industry today. These changes have affected not only our pilot population, but all those who support the operation – mechanics, gate agents, flight attendants, etc. In many ways, the glory is gone and it has become “just a job” to many people.

I share this situation to make the case that Sully is right, that young people choosing a profession today are less and less attracted to the future they see in the aviation.  In some ways, this is a national crisis that has been years in the making and will only come to fruition some years in the future when pilots and other specialists become scarce.  The law of supply and demand dictates that scarcity will force improvements in conditions, but not if there are less experienced pilots willing to take the jobs formerly held by pilots with much greater experience.

This was the point Sully was trying to make…we have to deal with today’s issues before they become tomorrow’s crisis. There are many ways to obtain flying experience, and no one of these is the “right” way. But, there is no substitute for experience in the cockpit to enhance safety and prepare one for the unexpected emergency such as Sully and his crew faced. We may be producing pilots but not nearly enough pilots with the robust training and background necessary to obtain the highest levels of competence in the cockpit.

Lest I seem all doom and gloom, there are solutions to these problems.  The beginning of solving any problem is awareness, and we’ll talk in future blogs about steps we can take now to avoid a crisis of experience later.

Fly Safely,

Captain Alan W. Price

Photos from Flickr. Photo credit: B777-223/ER on final approach to Ezeiza International Airport by Irargerich

“I always fly safely, knowing  that I will arrive at the scene of the accident a micro-second before you!”

Flying is statistically one of the safest ways to travel.  (In a future blog, we’ll discuss safety and the geography of commercial air travel.) Because of intentional redundancy in commercial aviation, what we call “defense in depth”, it is very rare for one person’s actions to lead to an accident.  System design is “fault tolerant and fail safe”, resistant to catastrophic breakdowns because it is created to ‘fail’ to an operationally safe condition.

Some years ago, Dr. James Reason proposed a “Swiss Cheese” accident model.  Picture a wedge of Swiss cheese, riddled with holes.  Shoot a bullet at the cheese.  Only a perfect shot can pass through all the holes cleanly.  If the wedge of cheese represents the aviation system and the bullet a breakdown or error, it would require a very rare set of circumstances for the bullet to pass through the cheese unobstructed, leading to an accident.

US Air Flight #1549, which ditched in the Hudson River in New York City on the 15th of January this year, and Continental Flight #3407, which crashed near Buffalo New York on the 12th of February, represent two such events.  (More about both of these accidents in a future blog)  In the “miracle on the Hudson”, a reverse perfect storm led to 100% survival; with the Continental crash, just the opposite was true and everyone perished.  Prior to these accidents, it had been almost 2 ½ years since the last US commercial accident. During that time, US airlines operated in excess of 16 million flights and transported over 2 billion passengers without a single accident or fatality!

Safety never occurs by accident, pardon the pun!  Rather, it results from many years of intentional design, continuous improvement, and thorough and rigorous standards and training.  Today’s safety system is built upon the knowledge gained from yesterday’s accidents.  Each accident teaches us invaluable lessons which are then applied to future operations.  Perfection is never possible.  It is, however, a constant goal.

It will be my pleasure in coming blogs to highlight different aspects of the commercial aviation system, and discuss current events such as the US Air, Continental, and Turkish Air accidents.  Your feedback will be essential so we’ll include a “because you asked” section to highlight issues and questions of importance to you.

During my many years as a captain, I made it a practice to greet my passengers during boarding.  Occasionally, they told me to “fly safe.”  My response was always the same – I always fly safely, knowing  that I will arrive at the scene of the accident a micro-second before you!
Stow your loose items, take your seats, and buckle up as we prepare for take-off on our flight into aviation history.  It will be my pleasure to be your captain on this and future flights.  Thanks for being with us today and welcome aboard.

Captain Alan W. Price