You might have landed here after reading this introduction LinkedIn post. If not, you might want to start there to understand the context better and enjoy others’ comments and insights on dropping safety
In a series of posts and articles, we have discussed dropping safety issues refreshing important concepts, theory, and best known practices worldwide.
But I am afraid that simply adding or reinforcing existing procedures does not guarantee compliance.
We still see and will continue to see aerial firefighting aircraft crashing during drops, sometimes with worse consequences than others.
When a failure occurs, our common reaction is to over-specify procedures—attempting to fix identified issues in an operation by creating increasingly detailed or narrowly focused rules that address the most recent incident.
While this may initially appear to enhance safety, the practice of inserting more, more intricate, or more conditional rules tends to widen the gap between procedures and actual practice, rather than closing it. Over time, these rules could become increasingly misaligned with the context-dependent and evolving nature of real-world operational practices.
The truth is, there will always be discrepancies between written guidelines and the way operations are carried out in practice, no matter how detailed our SOP´s or safety blogs are.
The earlier we understand that, and work on a more modern view of human error, the better
Understanding Human Error
When faced with an incident or accident characterized by significant human involvement, you may find yourself grappling with various conflicting and perplexing evaluations and actions taken by others. Essentially, you have two options, and your choice will shape the direction, inquiries, findings, and ultimately the effectiveness of your investigation, as well as the potential for advancements in safety:
1. You can attribute the mishap to human error.
In this scenario, “human error,” regardless of the specific label used—such as a loss of situational awareness, procedural violation, regulatory shortcomings, or managerial deficiencies—becomes the primary conclusion of your investigation.
2. Pilot mistakes tend to be a symptom of deeper trouble.
Human error is the starting point of our investigation, not the end. We should examine how human error is systematically connected to features of people’s tools, tasks, and operational/organizational environment.
Connecting people’s behavior with the circumstances that surrounded them points us to the sources of trouble and helps explain behavior from a psychological perspective and not purely on operational aspects.
No one goes to work with the intention of causing an accident.
Dying is not something anyone desires.
It’s not good for the individual missing out on the rest of their life, for their family and friends left behind, or for the organization.
We know it. We are aware of the procedures and standards, yet, we could still unintentionally deviate and get caught by the circumstances.
I would like to stick to the second option.
Why do we deviate?
The last part of the article 1: dropping safety – aerial assets, explores several organizational and industry factors that may contribute to these deviations.
➡️ Unsustainable growth. (Discussed here)
➡️ Not enough instructors or training resources.
➡️ Lack of mentors.
➡️ Inadequate or ineffective safety management systems.
➡️ Pilots left alone on single-crew ops too soon due to contractual needs.
Those are only a few. They could be more, and different in your organization.
We come to the conclusion that sometimes it could be the barrel and not as simlple as the apple…
- The bad barrel theory, places more emphasis on the role of the organization, its culture, and its systems in shaping individual behavior.
- It suggests that the environment or “barrel” in which individuals operate can have a significant influence on their actions.
- In this view, organizational culture, leadership, policies, and procedures can create conditions that either encourage or discourage unethical behavior.
- The theory posits that even well-intentioned individuals can be influenced to act unethically if they are placed in a toxic or dysfunctional organizational culture.
- Addressing the bad barrel theory involves examining and reforming the organizational structure, culture, and systems to promote ethical behavior and prevent misconduct.
In most cases, if we end up in a bad barrel, there are more chances that we end up being a rotten apple than we fix the barrel. The direction of the organization most likely will beyond our control unless act as managers in addition to being pilot.
If you can’t change things, do not wait until the system changes you.
We can always quit and choose our partners more carefully next time.
The Hanlon´s Razor – Barrels in bad conditions are not necessary bad barrels
On the same way as individuals acting as pilots do not go to work with the firm intention of causing an accident or perform an ineffective job, the same thing could happen with our managers and leader.
Sometimes, they cant cope or are too busy to get as deeps as the situation requires.
Never attribute to malice that which is adequately explained by ignorance.
Hanlon’s Razor states that, when trying to understand or explain someone’s actions or events, we should not immediately assume malice or malevolent intent as the cause. Instead, we should first consider the possibility of ignorance, misunderstanding, or simple incompetence as the more likely explanations.
In essence, this principle encourages us to give people the benefit of the doubt and attribute their actions to unintended mistakes or lack of knowledge rather than assuming they are acting with harmful intentions. It promotes a more charitable and empathetic perspective when interpreting the behavior of others.
The idea behind “Hanlon’s Razor” is that people often make errors or exhibit behavior that may seem negative, but it is not necessarily driven by evil motives.
Another Why beyond a “bad barrel”: Not seeing the bigger picture…losing perspective…wrong priorities
Furthermore, I want to emphasize that as the human aerial firefighters we are, we can struggle to see the bigger picture at times.
- What’s truly important?
- What should our priorities be?
In emergency situations, there’s pressure to perform, and various factors can compound the stress. This can lead to a loss of focus on priorities, target fixation and potential mistakes.
Let’s remember with a simple acronym that we need to S.E.E the bigger picture.
S.E.E:
1-Safe -> 2-Effective -> 3-Efficient
These priorities must be followed in that order.
IT MUST BE THE FOUNDATION OF YOUR OWN UNNEGOTIABLE INDIVIDUAL CULTURE
Regardless of the organization.
It cannot be Effective and Efficient without being Safe first.
YOU MUST BE ABLE TO COME BACK HOME EVERY DAY.
But neither you nor I are exempt from unconsciously pushing for effectiveness and efficiency without maintaining the necessary safety standards. This is a common pitfall, whether in the early stages of learning or when we’ve mastered an activity.
This issue is illustrated in the following graphs:
The conscious competence learning model
The Conscious Competence Learning Model, also known as the “Four Stages of Competence,” is a psychological framework that describes the process of acquiring new skills or knowledge. The model identifies four distinct stages through which individuals progress as they learn and develop expertise in a particular area
1. Unconscious Incompetence:
– In this initial stage, individuals are unaware of their lack of skill or knowledge in a specific area. They may not recognize the need to learn or may underestimate the complexity of the task.
– Essentially, they don’t know what they don’t know.
– This stage is often characterized by ignorance or a lack of awareness.
2. Conscious Incompetence:
– In this stage, individuals become aware of their lack of skill or knowledge. They recognize that there is a gap in their understanding or abilities.
– They may feel a sense of frustration or inadequacy as they confront their limitations.
– This stage is a critical step toward learning because individuals acknowledge the need for improvement.
3. Conscious Competence:
– As individuals progress, they begin to acquire new skills or knowledge consciously and deliberately.
– They must focus their attention and effort on the task at hand, often breaking it down into smaller steps.
– Competence is achieved through practice, repetition, and learning from mistakes.
– While they can perform the skill, it may require concentration and effort.
4. Unconscious Competence:
– In the final stage, individuals have mastered the skill to the point where it becomes second nature.
– They can perform the task effortlessly, without conscious thought or effort.
– Competence has become ingrained in their behavior, and they can do it almost instinctively.
We should recognize these stages in others and ensure that our frontliners progress beyond stage 1; Unconscious Incompetence.
That stage is a source of trouble.
We won’t be able to see it in ourselves because “we don’t know what we don’t know”.
Therefore, let’s keep an eye on each other…
The Performance VS Exposure chart
Another factor I would like to highlight is the performance vs exposure chart.
It comes to say that it is not safer who is less exposed, quite the contrary, it is safer who does more, who more and better trains, and who is exposed to an optimal amount of stressors “The sweet spot”. Watch out here because yielding to the minimum, kills, but performing to the maximum continuously, kills, too.
The following chart is similar to the previous one, but it adds a sharp fall in the end after the mastery phase that means terminal trouble.
That stage is a source of trouble too.
We won’t be able to see it in ourselves because “we know too much, and we could struggle due to ego and hierarchy factors”.
Therefore, let’s keep an eye on each other…
Let’s surround ourselves with individuals who aren’t afraid to point out when we might be deviating from our path.
Many people may tell us what they think we want to hear in an attempt to please us, but there are far fewer who are willing to explore uncomfortable topics alongside us.
Hormesis
The concept we have just landed with the exposure levels chart, in medicine it is called Hormesis.
The dose makes the poison.
A medicine can help or can kill. Same with exposure.
In conclusion
Accidents are painful but provide opportunities for learning and improvement, specially when it comes to human error.
When investigating, remember that human error is the beginning of the process, not the end.
Let’s prioritize safety while striving for effectiveness and efficiency, recognizing the stages of competence in ourselves if we can, but specially in others.
Finding the right balance of exposure is key, and we should remember the concept of Hormesis while we expose ourselves to stress
Stay safe!
