What All Chief Executives Should Know About Safety After American Airlines Flight 965 crashed near

Cali, Columbia, in December 1995, a senior executive, on hearing the CVR tapes, reportedly left the room shaking his head in disbelief. Here was one of his aircraft, involved in a fatal accident, under the control of a crew whose competence seemed to leave much to be desired. Of course, the causes of that accident are complex but who would have thought to include the airline's senior management in the line up of 'usual suspects' during the investigation? In 1998 a United Airlines 747 had an engine failure on take off from San Francisco. The use of incorrect technique by the First Officer (FO), who was flying the aircraft, resulted in stick shaker activation. The aircraft cleared San Bruno Mountain, 5 miles away, by 100 feet, missing the radio masts rising a further 600 feet above the mountain top. On investigation it was found that most FOs rarely handled the controls on take-off and landing other than in the simulator. It was also revealed that FOs regularly let their currency lapse, thereby gaining extra paid holiday while waiting for a simulator re-qualification. How would we assess the contribution of management in this case? As these examples show, events on the line occur at a distance from management activity. However, increasingly, the involvement of management in developing the context within which unsafe practices are allowed to develop is being questioned. Senior management undoubtedly has an interest in safety. The fatal crash of the DC-10 aircraft soon after its entry into service cost McDonnell-Douglas stockholders $200million. Even after it was discovered that faulty maintenance was a cause in the accident, the stock did not fully recover. In another study of airline brand-name value it was found that having an accident in which pilot error was cited as a cause cost the airline involved, on average, $27.3million in market value. Clearly, safety has a price. More important, share values count as far as senior executives are concerned, as CEO's will be judged on their airlines financial performance. However, in the UK at least, senior managers are now coming under legal as well as financial scrutiny. After several well-publicised disasters, the law of Corporate Manslaughter has been found wanting and new laws of corporate killing are being developed. In cases where safety can be proved to be well below acceptable standards, managers may find themselves in court. In this article, we want to explore the relationship between senior management activity and line operations and to consider what involvement in safety management we should expect from senior managers in future. Safety and Risk Management First, though what exactly are we expecting 'management' to be in control of? Safety can be defined as 'freedom from unnecessary risk'. Risk has 3 components: it supposes that a damaging event could occur; that the event has a certain probability of occurring; and that perceptions of that event will differ according to your point of view. This last component, standpoint, is significant in explaining differences between management and workforce attitudes to safety. The difficulties and dangers inherent in the workplace are encountered every day by employees but, in many cases, are largely invisible to management, especially if managers have not done the job themselves. Management activity aimed at improving productivity is readily understood whereas risk management activity, because of its ephemeral nature, is more problematical to envisage. However, if we accept that risk is an issue, then the next stage is to consider the burden of risk borne by an airline. We can identify a number of risk factors that will bear upon an airline's operation. External risk factors include weather and terrain. Internal risk factors include fatigue, the effects of

stress and competence. Some risk factors will be ever-present. For example, the weather, usually, will change during the time an aircraft is airborne - but it will never go away. Furthermore, weather forecasts are not perfect. Some risks will be variable, crew fatigue will vary according to length of duty period, and other risks will be compounded. For example, Maintenance service aircraft on the basis of some concept of a component's known time between failure but this is no guarantee that the component will not fail before its planned expiry date. A study of B-737s in the UK during 2001 found that airlines should anticipate a failure on take-off every 25 days and on final approach every 11 days. However, the malfunction itself may not be the problem but, as in the case of the United Airlines 747, it is how the crew deals with the event which will turn the risk into a hazard. Every airline, then, carries a burden of risk. What we are interested in is how management adds to that burden. The Role of Management Every airline will have a business model that represents how returns will be generated on the capital invested. Senior Managers will make decisions about which type of aircraft to fly and on what routes. What capacity to offer on each route. Whether to target charter or scheduled passenger traffic. Airlines can be distinguished in terms of their delivery of service and the cost of travel and, increasingly, the industry can be characterised by 2 largely overlapping dichotomies: no frills verses full service and low cost verses full fare. Economic activity, the generation of returns, gives rise to production processes, the daily activity associated with making money; in our case, transporting people and freight in aircraft. The business model will drive personnel management practices, such as the recruitment, training and rewarding of staff. Pilots and cabin crew represent 50% of the airline labour force and 33% of the cost structure. Given that capital equipment and fuel are, essentially, fixed costs, manpower costs also represent the easiest budget item to control. One UK airline found that by sub-contracting all of its ground handling it could save 6.7million. By recruiting staff on short-term contracts we can reduce the social costs of employment. We can illustrate the relationship between personnel policies and costs by looking at ground handling companies in the US. Companies whose employees remained, on average, longer than 5 years found that 68% of their capital equipment more than 10 years compared to only 32% for those companies whose employees remained for less than a year. Companies with the stable workforce had to replace 5% of capital equipment within 5 years of purchase compared to 18% for the employers with the transient workforce. Differences in staff retention can, in part, be explained by personnel management practices. All companies offered paid holidays, health insurance and pension plans although the number of companies offering these benefits was higher in the low turnover group than in the high wastage operators. Most significantly 95% of the 'stable' group offered paid holidays as opposed to 63% and 100% of the 'stable' group offered pension plans as opposed to 22% in the high turnover companies. The 'stable' companies also offered educational support and travel benefits. None of the high wastage companies included these benefits in their personnel management strategy Strategic management, then, can be measured in terms of cost, but what about risk? We said earlier that we can distinguish airlines in terms of their service offering. Part of service delivery includes activities within the aircraft cabin. When developing the cabin service, managers have a set of known quantities: the number of crew, the time available and the average load factor. A cabin service comprises a set of events, or iterations, all of which commit the cabin crew for periods of time. Furthermore, cabin crew engage in 'emotional labour', that is, they expend energy in dealing with passenger concerns, queries and complaints. The cabin service, especially on short sectors, usually allows no margin for unplanned activity, such as a medical problem or a disruptive passenger. Once additional

demands are placed on the finite cabin crew resource, then the potential for errors rises and burden of risk is increased. We can perhaps take the idea further if we look at the 'pit-stop' turn round adopted by most low-cost operators. To turn around a Boeing 737 in 25 minutes requires co-ordinated and efficient processes. Time really does mean money: Southwest have calculated that extending its ground handling by 10 minutes would require an additional 31 aircraft if it was still to meet its schedule. On the other hand, one Canadian operator noted that load factors of 76% resulted in delayed turn rounds and so it is using its revenue management programme to keep load factors below 75%. This way it can continue to meet deadlines while maintaining revenue but without resorting to extra aircraft. So, quick turn arounds are a part of the management strategy and they have a cost that can be measured, but do they add risk to the process? Ramp accidents are recognised as being an increasing problem within aviation, resulting in damage, injuries and fatalities every year. A 12-month study in the UK found that 483 flight deck and cabin crew and 608 ground support workers were injured on the ground, prior to the doors being closed for push-back. Some 214 air and 301 ground personnel were off work for more than 3 days because of sprains or muscle injuries. Furthermore, 39 air and 48 ground personnel fell out of aircraft doors and 50 air and 70 ground crew were struck by falling objects. Of course, these events cannot all attributed to quick turn rounds. However, low-cost operators are represented in the figures and it is well-known that activity under pressure of time is prone to error. Safety and productivity are almost mutually exclusive goals. In order to maintain production whilst guaranteeing some protection to the workforce and passengers, we need to strike a compromise. Workers are, of course, free agents within the work process and it is their actions that give rise to risky behaviour. However, management is in control of the production process. From Policy to Practice Broadly speaking, management directs, controls and provisions. Management gives direction by taking the business model and translating it into policies, procedures and working practices. Management controls activity through training and supervision. By provisioning, we mean the purchase and maintenance of everything needed to do the job. We want to look at the area of control in more detail because this is where the relationship between management and workforce is at its most tangible, and where things can go very wrong. Supervision of working practices is delegated by senior management to line management. The manner in which control is exercised on a daily basis will have an impact on safety. Employees strive to make sense of the work process through a framework of self-esteem and self-actualisation. In a sense, employees seek to work with dignity. Threats to workers' dignity come from mismanagement and abuse, overwork, limitations on employees' freedom of action and contradictions within the workplace, such as efforts to increase productivity disguised as 'quality' initiatives. Employees develop a range of tactics to safeguard their dignity. They develop ways to resist management-induced chaos, such as working to rule. They find ways to take pride in their work. They develop routines and beliefs that bring meaning to the task and, finally, they develop workplace relationships, thereby drawing strength from group solidarity. Management style will indirectly influence employee behaviour and, in turn, safety. However, more direct control can be exercised through training. People bring to the workplace a degree of competence but, at the same time, competent performance contains a degree of variability; we all have a bad day. Management will take decisions about what to train and to what standard, decisions that will be driven by cost. All training analysts know

that there is a gap between the proficiency attained in training and the proficiency required in the workplace. This gap, the difference between the training performance standard and the operational performance standard, has to be bridged and the effectiveness with which that bridging occurs will also influence the burden of risk borne by the airline. Bringing Management back into the Loop The relationship between airline management and unsafe working practices occurs both indirectly, through the impact of the business model on organisational structure and function, and directly, through the agency of day-to-day management. How management can regain control of the process? We need to remember, at this point, that things go wrong because people make errors. Although we now recognise that organisational factors can influence events, it is important to recognise that effective safety management needs to address individual as well as organisational problems. It is probably fair to say that most airlines do not know how unsafe they are. We can picture an airline as operating within a bounded 'safety' space. Provided that there are no accidents or incidents, all we can say is that we are somewhere in that space, but we do not know where. Adverse events reveal when we step outside of the safety space but, for the rest of the time, we could be dead centre or close to the edge. It is also probably true that line personnel have a better understanding of safety issues, and how to fix them, than does management but without effective way to capture knowledge, such expertise is unavailable to the organisation. Knowing the bounds of the safety space would be a definite, albeit probably unattainable, advantage. What can be measured, though, is performance. We badly need performance indicators that show the relationship between management activity, worker performance and safety. Employee attitudes seem to be a prime candidate and we can identify 3, in particular, which might be worth taking further: attitude to management, to the job and, finally, to safety generally. Attitudes represent soft measures of performance. With the development of more-capable flight data recorders, together with rapid downloading and analysis systems, we can now look at hard data which may allow management to identify where the airline sits within its safety space and what are the threats to safety. The use of flight data is not without problems. Just as the road haulage industry fought against installing tachographs, data recorders, to monitor driver duty times so airline pilots have resisted performance tracking. The use of hard data will require a change of attitude on the part of management and those workers affected by it. Whatever data is captured, we need more effective systems to exploit the information gained. Most JAA airlines have developed Quality Plans and the principles of Total Quality Management provide a model which could be adapted to the needs of safety management. The current spate of acronyms - SMS, FOQA/OFDM, LOSA, AQP - are really no more than bits of the jigsaw, neither mutually exclusive nor representing a complete solution. However, we can exploit these ideas to build a system which provides the feedback to management necessary for safe operations. On the one hand, management needs to understand the relationship between the business model and unsafe working practices and, on the other hand, management needs to be in control of the gap between training and the realities of line operations. Soft measures will probably meet the former need whilst a data-driven training system will satisfy the latter. Implicit in all of this, though, is that management will finally start to manage safe and efficient operations. The failure to do so will leave airlines lost in safety space.