Airline Aviation Safety - Essay Example

Running Head: AIRLINE AVIATION SAFETY Airline Aviation Safety of the of the Airline Aviation Safety Introduction The role of human factors in aviation has its roots in the earliest days of aviation. The pioneers of aviation had their concerns for the welfare of those who flew their aircraft (particularly themselves), and as the capabilities of the vehicles were expanded, the aircraft rapidly exceeded human capability of directly sensing and responding to the vehicle and the environment to effectively exert sufficient control to ensure the optimum outcome, safety of flight. The first flight of only 12 sec. in which Orville Wright flew 540 ft. was on Thursday, December 17, 1903. The fourth and final flight of that day was made by Wilbur for 59 sec. and traversed 825 ft. The purposes of aviation were principally adventure and discovery. To see an airplane fly was indeed unique to actually fly an airplane was a daring feat. The early pioneers did not take it lightly, for to do so meant flirting with death in these fragile unstable craft. Thus, the earliest aviation was restricted to relatively straight and level flight and fairly level turns. The flights were performed under visual conditions in places carefully selected for elevation, clear surroundings, and certain breeze advantages to get the craft into the air sooner and land at the slowest possible ground speed. The greatest problems with early flight were the reliability of the propulsion system and the strength and stability of the airframe. Many accidents and some fatalities occurred because of the structural failure of an airplane component or the failure of the engine to continue to produce power. Although human factors were not identified as a scientific discipline at this time, there were serious human factors problems in the early stages of flight. The protection of the pilot from the elements, as he sat out in his chair facing them head on, was merely a transfer of technology from bicycles and automobiles. The pilots wore goggles, topcoats, and gloves similar to those used when driving the automobiles of that period. Crash Of Valujet Flight 592: A Case Study Of Human Errors On the morning after the crash of ValuJet Flight 592, United States Secretary of Transportation Federico Pena appeared on television to re-affirm the safety of flying on ValuJet: "I've flown ValuJet. ValuJet is a safe airline, as is our entire aviation system" (Navarro, 1996, p. A1). Pena also added a strong endorsement for ValuJet's management team: "Whenever we have found any issues, ValuJet has been responsive, they have been cooperative, they have in some cases even exceeded the safety standards that we have" (Navarro, 1996, p. A1). Senior Federal Aviation Administration (FAA) officer David Hinson echoed Pena's sentiments about the safety of flying ValuJet. Three days later, a preliminary inquiry by the National Transportation Safety Board (NTSB) concluded that oxygen canisters being shipped in the cargo hold ignited a fire that brought the plane down shortly after its take off (Wald, 1996a, p. A1). Vincent, Crow, and Davis (1997) contend that an airline crash provides a compelling and visually powerful news story. Vincent et al. maintain that "the events which surround air crashes are inherently dramatic, involving life and death situations, heroic actions, fatal and fateful decisions, and unforgettable visual images" (p. 354). Part of the appeal of a crash occurs because it involves ordinary people. Part of the appeal of a crash occurs because of the very randomness of the act, and the potential for a similar random act to affect millions of other air travelers. Vincent et al. perceive an airline crash to constitute a rich text with three overarching story lines: (1) "The tragic intervention of fate into everyday life" (2) "The mystery of what caused the crash" and (3) "The work of legitimate authority to restore normalcy" (p. 357). In the case of ValuJet Flight 592, these themes were altered slightly by the recurrent suspicion that legitimate authorities had failed to safeguard the public welfare, and that the efforts to restore "normalcy" were being compromised by the FAA's desire to promote the low-cost, no frills segment of the aviation industry. An organization is inherently vulnerable to a crisis because events are likely to occur that are beyond its control, or are caused by human error and misjudgment, or that involve decisions between conflicting but equally admirable goals. Thus, harmful, counterproductive, and offensive behaviors occur, leaving an organization "vulnerable to attack" (p. 67). ValuJet began operations on 26 October 1993, using eighteen DC-9's purchased from Delta Airlines. The planes within ValuJet's fleet were used or reconditioned aircrafts. ValuJet's central objective was to offer fares at fifty to sixty percent less than the major carriers and to outsource maintenance to the lowest bidding repair services, thereby eliminating the need for costly repair facilities, expensive parts bins, and mechanics of its own. By and large, ValuJet completely cut out frills across the board: Passengers were offered no meals, no seat reservations, no printed tickets or city-ticket offices, no frequent flyer programs, and discounted prices were not even available to the airline's employees (Schiavo, 1997b, p. 7). ValuJet's market niche was based strictly upon offering a cost-sensitive flight; its customers were not promised quality, service, or convenience. Moreover, ValuJet placed a heavy emphasis on cost containment in order to maximize its profits. ValuJet's maintenance programs were scattered among fifty different contractors at eighteen companies until eventually the airline began to postpone critical repairs in order to keep its busy schedule afloat (Schiavo, 1997b, p. 12). ValuJet unfortunately failed to heed the multiple warning signs during the prodromal stage. Instead, it continued to expand at a dangerous rate while relying exclusively upon older and reconditioned planes. Accidents occurred, and the numbers were extremely high by industry standards. The company's pilots made fifteen emergency landings in 1994, fifty-seven in 1995, and fifty-nine in the first few months of 1996 (McFadden, 1996, p. 1A). Mary Schiavo (1997a), the Transportation Inspector General, reports that from February through May of 1996, a ValuJet airplane was forced down almost every other day (p. 56). The NTSB indicated that "ValuJet's accident reports were four times greater than other airlines including United, Delta, or American" (Ho, 1996, p. A13). Just as ValuJet's management team ignored the early warning signs of major problems, the FAA failed to monitor ValuJet's performance during the prodromal stage. Thus, the public's regulatory net designed to ensure optimal safety measures was compromised from the outset. The FAA's 1958 mandate was to "promote" and "police" aviation. But the FAA, when faced with a conflict of interest, tended to emphasize the former goal while ignoring the latter. The FAA had a self-serving policy objective in promoting ValuJet as an exemplar to prove that deregulation actually was fostering competition within the airline industry. That goal overshadowed its obligation to police the safety violations and accident records of ValuJet. Schiavo (1997a) reports that "The FAA looked at ValuJet planes nearly 5,000 times in the three years that it had been flying yet had never reported any significant problems or concerns" (p. 56). The acute stage of the crisis exhibited several of the transformations that Fink's (1986) model predicts. First, the situation attracted increased governmental scrutiny as the FAA launched a belated but intensified review of the safety and maintenance records of ValuJet. At the White House, top presidential aides Harold Ickes and George Stephanopoulos berated Transportation Secretary Pena for reassuring the public about ValuJet. The Wail Street Journal reported on the White House's new "marching orders" for the FAA and Department of Transportation (DOT): "Nobody mentions ValuJet' when talking about airline safety." The objective, the story continued, "Was to stop the perception of boosterism" ("Transportation Chief Pena," 1996, p. 1). Second, media coverage of the event increased dramatically, moving the emergence of the discount segment of the airline industry from an "undisclosed problem to a receptacle of attention" (Fink, 1986, p. 23). This coverage tended to question the prevailing myth that all airlines were equally safe, and that the small-non-unionized carriers were as safe as the mainstream companies (Bryant, 1996b, p. B10). Third, the credibility of ValuJet's safety and maintenance records were open to dispute as various claimants emerged to contest ValuJet's commitment to safety. Fourth, critical distractions occurred that disrupted ValuJet's normal business activities. The FAA's intensive inspections forced ValuJet to reduce its scheduled trips to only a handful a day, and flight cancellations and inspection-related delays further prompted customers to cancel future bookings (Wald, 1996b, p. A7). Fifth, the financial well-being of the company was placed in jeopardy as the stock dropped twenty-seven percent within a few days of the crash (Gleick, 1996, p. 42). The emerging image that the company was not being safety-conscious directly hurt its viability with analysts on Wall Street. During the acute and chronic stages of the crisis, one of the key problems that ValuJet faced was its inability to display a genuine commitment to safety. Safety is still the overarching value to which all parties in the aviation system defer and must affirm in their varied accounts of how the overall system should function (Perrow, 1999, pp. 382-383). ValuJet's concern with profits and efficiency made the organization appear as if it had downgraded safety in favor of other goals. After the crash, Jordan's varied rhetorical strategies unfailingly paid homage to the central value of safety as ValuJet's number one priority, but neither the public nor the media were persuaded of ValuJet's actual commitment to safety. ValuJet seemed to be only paying lip service to the "god-term" of aviation while attempting to restore its positive image. The most favorable response to ValuJet's strategy came from the DOT, which accepted ValuJet's argument that it needed to keep the planes in constant use to meet its demanding schedule, and thus safety "unwittingly" was downgraded as a top priority. This was an argument based upon what Benoit (1995b) has called "defeasibility" and "accidental occurrences." But it was not an argument that the media or the public treated sympathetically. Human error: does it exist A macro approach to safety introduces the opportunity for reflection on human error. An analysis of human performance in safety events is largely conducted with abstraction of contextual influences. Furthermore, aviation research on human judgment and decision-making has until recently been conducted out of context and it has ignored the natural component of the decision-making process. Such research has been applied as a template to measure human performance-and therefore error-in different cultures and operational contexts. Likewise, errors have been considered to emerge from either the technology or the human, but seldom from the joint human-technology system. The weakness in this approach becomes evident when considering the influence technology exerts upon human and organizational performance. It becomes more so when considering that, in spite of abundant research and the development of prescriptive/normative models for aviation training in judgment and decision-making, both continue to be assessed as prevailing factors in safety breakdowns (Klein et al. 1993). Conventional analysis on human error in aviation backtracks an event under scrutiny until a point at which analysts find a particular kind of human or organizational performance that produced results other than those intended by the actors. At that point, human error is pronounced. This, with limited consideration of the process leading to and with the knowledge of, the bad' outcome, obvious to the analysts but certainly unknown to the actors, a priori of the bad' outcome. This analysis largely ignores the conditions as presented at the time the event took place, and which may have influenced the improper' performance. It also neglects the organizational culture that gives meaning to events and performance. From this perspective, consideration of human error is a reactive judgment--the harshness of which is proportional to the magnitude of the bad' outcome--on what at the time of the event was perceived to be a normal performance by the actors (Amalberti 1996). Further weaknesses of this analysis of error come to light when considering that because of aviation's defenses, the relationship between process and outcome is not linear: numerous errors are committed during routine operations which seldom result in bad outcomes. Monitoring systems indicate instances in which bad' processes result in good' outcomes, because of system defenses. Likewise, relatively good' processes result in bad' outcomes--often because of chance. Although the relationship between process and outcome is loose in terms of causality, the concept has yet to penetrate the armor of aviation's prevailing convention. Therefore, the fact remains that, unless a bad outcome exists, human error is not pronounced. Finally, in aviation, with the inherent competition between production and safety goals, operational decision-making (and therefore error) must balance both production and safety demands. The optimum performance to achieve the production demands may not always be fully compatible with the optimum performance to achieve the safety demands. Operational decision-making lies at the intersection of production and safety, and is therefore a compromise. In fact, it might be argued that the trademark of experts is how effectively they manage this compromise. A current safety paradigm should therefore consider errors as symptoms rather than grounds of safety breakdowns, because error-inducing factors are hidden in the context, largely bred by the balancing conciliation between safety and production. In addition, aviation must acknowledge that error is a normal component of human performance. This reinforces the value of monitoring and reporting systems, so that error-inducing factors are uncovered before they combine with flaws in human and organizational performance to produce safety breakdowns. Most important, assessing that an error--be it individual or organizational--has occurred should be the starting rather than the stopping point of the safety investigation process. Digging into the architecture of the system will yield to countermeasures aimed at error detection, error tolerance and error recovery, rather than to pathetic efforts aimed at error suppression. The role of the accident investigation process The failures in basic organizational processes, such as allocation of resources, planning, budgeting, financing, establishing goals and so forth, are the causes behind the symptoms observed in flight decks, in air traffic control rooms, in ramps and in maintenance hangars. While it is important to address symptoms while longer-term strategies aimed at the causes' take place, it would be regrettable if all energies continue to be devoted to myopic attempts to address symptoms exclusively. While accident investigation must be recognized for its historical contribution to aviation safety, the industry cannot afford to use up meager resources in reactive endeavors. It cannot afford--either ethically or financially--to wait for accidents to learn safety lessons. More importantly, it need not wait. At the heart of this paper is the contention that, through the application of human factors knowledge to prevention strategies, there exists the possibility of proactively anticipating those flaws which already exist in the system and which will eventually lead to accidents. It is possible to apply techniques to identify latent unsafe conditions within the system, before they combine with failures in operational contexts to provoke accidents. Conclusion The growth in aircraft system complexity is exponential in many areas, with the most significant trend being the interconnectedness of systems. Current-generation aircraft operate as highly integrated systems with extensive cross-linking. As system complexity grows, so does the concern about hidden design flaws or possible equipment defects. Accidents involving complex systems and events present investigators with new and different failure modes that multiply the number of potential scenarios they must consider. The historically common causes of accidents are occurring less frequently, leaving more challenging accidents to diagnose. Within the aviation industry, human factors is not an end in itself, an opportunity to generate research, nor the last frontier of aviation safety or a frontier of any kind. The incorporation of human factors knowledge into aviation operations and practices presents another opportunity to contribute to the aviation system's production goals: the safe and efficient transportation of people and goods. If human factors knowledge is expected to be effective against systemic flaws and failures, its application must be predicated upon an understanding of systemic safety and a safety paradigm that are relevant to contemporary civil aviation. Some encouraging progress has been made, but there is need for improvement. References Amalberti, R. 1996, La Conduite De Systemes A Risques (Paris: Presses Universitaires De France Benoit, W. L. (1995b). Accounts, excuses and apologies: A theory of image restoration strategies. Albany NY: State University of New York Press. Bryant, A. (1996b, May 20). FAA fries show early lapses by ValuJet. The New York Times, p. B10. Fink, S. (1986). Crisis management: Planning for the inevitable. New York: American Management Association. Gleick, E. (1996, May 27). Does air safety have a price Time, pp. 40-42. Ho, R. (1996, May 12). The crash of Flight 592. The Atlanta Journal and Constitution, pp. A13. Klein, G. A, Orasanu, J., Calderwood, R. And Zsambok, C. E. 1993, Decision Making In Action: Models And Methods (Norwood, NJ: Ablex). McFadden, R.D. (1996, May 12). Atlanta flight was making emergency return to Miami. The New York Times, pp. 1A, 22A. Navarro, M. (1996, May 13). Hope of rescue is swallowed by swamp. The New York Times, pp. A1, B7. Pena says ValuJet followed safety rules. (1996, May 13). CNN Interactive OnLine. Retrieved July 8, 2006 from the World Wide Web: http://www.cnn.com.us/9605/12/crash.pena.idex/htm Perrow, C. (1999). Normal accidents: Living with high-risk technologies. Princeton, NJ: Princeton University Press. Schiavo, M. (1997a, March 31). Flying into trouble. Time, pp. 52-62. Schiavo, M. (1997b). Flying blind, flying safe. New York: Avon Books. Vincent, R.C., Crow, B.K. & Davis, D.K. (1997). When technology fails: The drama of airline crashes in network television news. In D. Berkowitz (ed.), Social meanings of the news (pp. 351361). Thousand Oaks, CA: Sage. Wald, M.L. (1996a, May 17). Clerk's mistake may have put volatile chemicals on ValuJet plane. The New York Times, p. A1, A16. Wald, M.L. (1996b, May 18). F.A.A. cites problems with airline and oversight. The New York Times, p. A7. Read More