Which should we strive for? Perfection or Better Performance? The question was the result of reading Matt Zuccaro’s recent column, “Zero Accidents: Yes, We Can.”
Matt is the president of the Helicopter Association International. He’s also not afraid to say what’s on his mind.
Don’t believe me? Take a look at Matt’s opening paragraph: “Call me crazy, call me insane — I don’t care. I truly believe we can achieve zero accidents in the helicopter industry. Maybe not tomorrow, not in the next few years, or not even in my lifetime. But ultimately we can and will accomplish this goal.”
A few lines later, Matt reiterates his point: “There is only one safety goal we should work toward, and that is zero accidents in the helicopter industry.”
At first read, I was shaking my head. No. No. No.
Accidents do happen. And they will happen. It is irresponsible to expect zero accidents. After all, the only way to truly ensure zero accidents is to never take off.
My immediate fear was that of regulators making it all too easy to help the industry achieve zero accidents. “Let’s ground all the helicopters,” they’ll say. Followed by, “You’re welcome. We just helped you achieve your goal.”
To see if my line of thought made sense, I asked my oldest daughter — Savannah — her opinion. Perfect or Better? I framed it in the context of aviation safety. Savannah asked, “how much better? What’s an acceptable improvement?” Hmm… she’s too smart for me.
Matt’s column covered that one… “Does it really make sense to say “let’s reduce accidents by 20%? That’s just another way of saying ‘we had five accidents this year, and next year we want to have four.’” Mind you, Savannah hasn’t yet read Matt’s column.
When framed as a sports analogy, does any team start a season with the goal of all wins (zero accidents)? Did the 1972 Miami Dolphins (the NFL’s only undefeated, untied team) start the season with all victories as the goal? What about John Wooden at UCLA? They won 10 championships in 12 seasons and 88 consecutive games at one point. When they lost that 89th game, was their season lost? Had they failed to achieve zero accidents?
What about the University of Connecticut Huskies women’s basketball team. They have an active winning streak of 101 games (as of Feb. 18). Their last loss was on Dec. 17, 2014. to Stanford — their only loss that season en route to a national championship. Did they fail to achieve zero accidents?
I say no. They kept their eye on the prize: The championship. They all played one game, one half, one quarter, one play at a time.
As I think back on the many flights I’ve made around the country, I’ve spent many hours (days even) on the ground, wishing I were in the air. That’s the way that axiom is supposed to work, right? I didn’t ground myself to keep my perfect streak of accident free flying intact. I made my decisions based on those flights. Period.
“Decision-making and risk assessment must focus on one question: Can we complete this operation safely?” asks Matt. “Stop worrying about disappointing the boss or customer, risking the contract, or even saving a life — let’s just focus on conducting a safe operation. The only plan worth sticking to is a plan to conduct a thorough preflight, assess and mitigate flight risks, and practice good aeronautical decision-making, with a safe landing as the goal.”
Here’s where I get on board with Matt’s thinking. Perhaps I’m just being slow to understand. Maybe it is a matter of semantics. Maybe I do agree with what he means, while I disagree (or don’t fully understand) the manner in which he says it. On second — and third — reading of Matt’s column, I find my head nodding in agreement much more.
Zero accidents can only happen one pilot, one aircraft, and one flight at a time. It is not a decree from on high. When a situation arises, how we react is everything.
Do yourself a favor and read Matt’s column for yourself… then tell me, is he crazy? Is Matt insane? If he is, I might be as well after all.
What about you? Are you crazy?
“Zero accidents” sounds good – as one might expect of a slogan born in Washington DC – but it fails on at least two fronts, as a practical safety goal and as an aviation trade association statement. As to practical safety, aviation operations are like any other complex human endeavor; they cannot be made error-free, so error identification and trapping, procedural as well as mechanical redundancy, and vigorous situational awareness are the keys to improvement. In the 20th century, Jonathan Deming led a revolution in quality control that saw Japanese industries leapfrog their American competitors by admitting that bad things happen, using rigorous methods to maintain heightened situational awareness, identifying instances of failure early in processes before consequences started to snowball, and weeding out the failures to yield dramatic net improvements in quality. American industry leveled the field by adopting similar approaches to QC. Mr. Zuccaro would do his industry a great favor by calling for enhanced procedural QC and helping refine it for helicopter operations rather than pointing to mythical, unattainable goals. This leads to the second point: the commercial helicopter industry has, in fact, an exemplary safety record. Many helicopters operate commercially in challenging environments, performing operations that are exposed to necessary risk. The helicopter industry deserves great and loud praise for controlling and mitigating those risks to perform operations that are socially as well as commercially invaluable with levels of success and safety that are truly outstanding. Mr. Zuccaro’s quixotic crusade, misguided though it is, may be expected of an organization devoted to criticizing industry; the obvious 20th century example is Ralph Nader and his various organizations. But for so misguided a critique to issue from the industry’s own trade association is nothing short of breathtaking – and not in a good way.
Striving for zero accidents is a worthy goal, but achieving that goal is impossible due to the complexity of our aviation environment. The newest thinking in aviation safety is represented in Sidney Dekker’s “Just Culture: and “Drifting into Failure” See: https://youtu.be/pYlIEMNhqM4 This system level analysis of safety shows that errors are unfortunately inevitable despite incredible human effort.
The only encouraging side to this larger system-level perspective is that human efforts are now viewed as “noncriminal” This newest FAA vision (2015) is called “compliance philosophy.” Since there is no criminality or blame if a pilot tried real hard and still failed (as in a non-intentional deviation or violation) we can share how our error occurred (like expanded NASA reporting) and everyone can improve their safety and system.
Instead of violating a pilot, the new FAA policy is counseling and “more training” https://www.faa.gov/about/initiatives/cp/ We have picked all the low hanging fruit in aviation safety and some risk is inevitable if we value the freedom we enjoy to do exciting and adventurous things in the air.