Risk management

Dr. Robert M. Gresham, Contributing Editor | TLT Lubrication Fundamentals November 2011

Lessons from people who set the standards for safety—the airlines.
 


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NOW I LOVE MY WIFE. Yet, some things about her are an enigma to me. She is very much afraid of flying, especially small prop planes. She is an Olympic-level backseat driver. Yet she rides horses and skis with wild abandon. The statistics on plane flight suggest that it is one of the safest activities you can do. Statistics on her other two activities are infinitely less safe.

So what’s going on here?

At the recent 4th Symposium on Metalworking Removal Fluids: Global Challenges in Barcelona, Spain, one of the keynote speakers, Mr. Manfred Muller with Lufthansa, spoke on the subject of risk management in the airline industry. I would like to share some of his insights.

Mr. Muller notes that with 750,000 flights per year at Lufthansa, you were 99.99997% safe—that’s pretty safe! By comparison, mountain climbing was more like 40% safe, NASA accepts 96% and hospitals (medical malpractice) only 98%. Regardless of my wife’s phobia, flying is incredibly safe. This is not about rationality.

According to Mr. Muller, this mindset relates to the human condition that we are willing to accept much more risk if that risk is self-determined; if that risk is foreign-determined we will not accept anywhere near as much risk. In the case of air flight, we humans, my wife in particular, tend to not accept any risk at all. But of course 100% safe is not possible.

So how does an industry like the airlines manage risk when their customers’ expectations are so high? One is tempted to think that engineering controls like high-tech instrumentation, so-called fly-by-wire technology and related technological advances have resulted in the airlines’ outstanding safety record.

These advances most certainly have made a significant contribution. Because of the advanced design of today’s aircraft and the high level of training of flight crews, most mechanical problems, which are few, can be further ameliorated by the crew. So this alone is not the answer.

More important, the airlines study the factors that make up a threat to flight and their probability of occurrence. For example, the probabilities for ditching are 10-8; terror 10-7 and human error 10-4. Clearly, human error exceeds terrorist attack by three orders of magnitude. Indeed, 75% of all accidents are related to human error. In turn, human error is made up of a combination of three components: operational, human and social interaction. The airlines discovered that they could eliminate 80% of human errors by optimizing human interaction. However, this is not so easy.

Operationally, we all are aware of the need for SOPs (standard operating procedures), but we humans inherently don’t like them, preferring instead to “do our own thing,” which can lead to errors. Additionally, in terms of social interaction, the hierarchy of management, chain of command (top down), must be just right or an employee will not report problems, make suggestions or offer criticisms for fear of punishment. In some cases, this fear to say something, especially in a timely manner, could lead to a disaster. Or the captain might not pay attention to the suggestions of the crew. Yet, if the chain of command is too horizontal, a lack of discipline results. So the key is to make sure the hierarchal relationships have the right balance between vertical and horizontal.


The airlines discovered that they could eliminate 80% of human errors by optimizing human interaction. However, this is not so easy.
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DESK
Mr. Muller uses the acronym DESK, which relates to the balance between discipline, engagement (motivation), social, and (K) cooperation. To achieve DESK, Lufthansa balances optimum hierarchy, active and passive criticism, open communication, non-punitive error management (reporting of errors, whether the employee’s or those of others, is kept confidential). This is contrasted by comparison to the legal system where mistakes are prohibited, all mistakes must be reported, and all mistakes are punished.

With this as a backdrop, I could not help but reflect on my own past performance as a new production supervisor at DuPont. In our building, we ran several processes that, if allowed to get out of control, literally could leave a crater where the building stood. For example, we made dinitroaniline which is very similar in terms of explosive potential to trinitrotoluene—TNT. We had 10 1,500-gallon reactors of the stuff going pretty much all the time.

Under my supervision were dye intermediates based on diazo compounds of various nitro anilines, one of which was 88% as powerful as TNT if detonated. So as you might guess, we were into risk management long before it was a buzz word.

At the time, DuPont was very big on engineering controls to sense problems before they got out of control as well as automatic systems to deal with an out-of-control reactor. Indeed, we had typically five levels of various kinds of controls. Yet, more than once in my three years there we somehow managed to work our way through all five. So why am I still on the planet?

By the time I got the call, it was usually too late—the building was evacuated and fire trucks were on standby. What saved the situation was the performance of the foremen and operators we had in the building—the frontline people. Without any formal training, we had foremen who worked their way into the job. Their teams generally respected them because they had all worked side-by-side, and while the foreman still made the final decisions and was ultimately responsible, the relationships were largely collaborative. If not, the foremen usually assigned the individual to tasks other than running the reactors or found ways to get the person off his shift.

So when there was a problem, more often than not a human error, the operator told the foreman as soon as he detected that something wasn’t right, the foreman took corrective action, and most of the time everything turned out fine or at least manageable.

At the end of the day, we were implementing many of the principles that Mr. Muller from Lufthansa described, although not in a formalized way. We learned from our mistakes. The senior foremen, some with 30-plus years’ experience in the building, taught the shift foremen—and me. Indeed, this is one of the reasons why there is an experience requirement in our certifications, and why most captain-level pilots of major airlines are sporting a little silver hair.

So by understanding that we as humans are most averse to risk we cannot control, and by managing the risk that we can control, especially the human side, to acceptable statistical levels, we have achieved outstanding safety records in many of our industries worldwide—most notably the airline industry.

And to the betterment of my marriage, I now fully understand why my wife doesn’t like to fly and revels in making sure that I always drive up to the proper standard—hers.
 

Bob Gresham is STLE’s director of professional development. You can reach him at rgresham@stle.org.