Aviation Safety is an area hospitals and the health system should examine to assist in the evolution of a better standard of safety for their patients. To most it would appear rather incongruous that commercial aviation has any advice to offer other industries, however in an industry where costs are staggeringly high, volatile and variable, and profits are seasonal and marginal, safety remains a constant. A common saying within the industry is; if you think safety is expensive, try having an accident.
It is important to differentiate commercial profitability from operational performance, and to recognise that profitable or not, the one thing that most airlines have in common is safety. Despite considerable growth in the industry over the past two decades the rate of aircraft accidents has fallen by over 50 per cent . Though in that time, the technology in aircraft design and operation has improved, today’s new generation aircraft share the skies with many second and even third generation aircraft.
Aviation Safety – Paradox or Perspective?
Aviation today is one of the safest industries in the world, representing less than one fatality per million flights. Despite an ever increasing volume of flights, and the most competitive aviation marketplace ever, this is an extraordinary feat, particularly given the high risk nature of the industry. Early methods of safety management involved extremely restrictive management of the industry by the civil aviation regulatory bodies of each country. For many years safety systems in aviation were seen as a necessary evil – costly and constraining; a rule, not a mantra. The industry was overburdened by regulation that not only controlled the way airlines operated, but also who would operate on what route and, to some extent, what fares they could charge. Efficiency seemed unnecessary as airlines would pass the costs directly on to the public, safe in the knowledge that they were commercially protected. Undoubtedly, such governance contributed to the risk landscape by passively absolving the airlines of responsibility for issues such as safety. Perhaps this is the most fundamental point of relevance for other regulated industries, such as health and hospitals.
Two decades ago, with the de-regulation of the industry, regulatory control by the civil aviation bodies changed to regulatory oversight, forcing control back on to the airlines. Airlines were now required to self-audit their safety systems and to demonstrate compliance to the regulator. Regulators took a far more supportive position and encouraged the airlines to reveal any non-compliance without fear of retribution; indeed, trust became the trade-off; regulators would loosen their control on the airline’s activities in return for their uncompromising duty of disclosure. This change in approach was to play a major part in creating an industry-wide approach to safety.
Nevertheless, trust is difficult to enforce and so the regulators required the airlines to identify key personnel who would be responsible for their airline’s compliance. Known as Postholders, these individuals had to be highly skilled and qualified in specific areas such as Flight Operations and Engineering, and would be personally responsible, and legally accountable, for ensuring that the airline complied with all regulatory requirements. Further, their accountabilities couldn’t be deferred or delegated to others, and whilst these individuals reported normally through their internal company structures commercially, from a regulatory perspective they reported directly to the Civil Aviation Authority. Feeling the weight of individual exposure Postholders motivated the establishment of safety, quality control and auditing departments, with direct line of sight to the Postholder, the CEO, and in the instance of safety, to the regulator. Safety now became everyone’s business, and responsibility for it was being filtered down to the lowest levels in the airlines.
Make no doubt about it, safety is expensive. It is also highly constraining to commercial freedom. And yet, after half a century of development airlines understand that safety is the one true commercial priority. Without it seats don’t get sold. Today’s airlines enjoy the stability that it provides to their business, setting a foundation upon which they can confidently explore commercial opportunities. This is simply a change of perspective; constraint and cost are the antithesis of commercial competitiveness, however, in an industry of huge technical and environmental variables juxtaposed with intense commercial pressures, they provide an essential bounding that ensures that no matter how the commercial situation may change the airline remains safe. Constraint becomes freedom. Once understood it becomes habitual or cultural.
Safety Systems – Controlling the Variables
Today’s modern aviation systems were borne of a time when safety, or the lack of it, was a discovery usually identified in the aftermath of an aircraft accident. Though the industry continues to learn through discovery, it is now far more knowledgeable and importantly, highly cognisant of what it does not know.
The operation of a commercial aircraft is a highly technical procedure. Not only do operators have to deal with the complexity of the aircraft itself and the hundreds of machines it incorporates, but they also have to do so in an environment on which it is utterly dependent, and which is subject to extreme variability, often with little notice.
In an environment saturated with risk, it is simply impossible to remove every threat, both from a practical and financial point of view – removing every risk means never leaving the ground. Instead the industry has learnt to identify and value each risk, and where those risks cannot be removed either because they cannot be immediately identified or because they arise as a consequence of another seemingly innocent action or event, the acknowledgment that they exist under certain circumstances creates a heightened level of surveillance and situational awareness in the cockpit and supporting areas.
Given the modernisation of aircraft, improved technical performance, normally benign weather conditions, and the familiarity of operation to the point of monotony, pilot training has been expanded to compensate for the natural tendency to become complacent. Mandatory pilot competency and proficiency evaluations occur at least twice a year and training is rigorously focused on standard operating procedures to the point where the pilot’s actions in normal or disruptive situations are second nature.
Today’s cockpit environment remains strongly hierarchical and yet operates as a co-operative and dynamic interplay between individuals. Crew Resource Management (CRM) has evolved with the industry and is founded on the premise that human error is omnipresent and as such training focuses on counter-measures to error, including avoidance, capture and recovery. Importantly, the training recognises that not all examples of error in the cockpit have an immediate outcome in the form of an accident, but usually set in place a compounding series of events that consequently result in an accident, therein providing pilots with opportunities for intervention.
The combination of rigorous adherence to standard operating procedures with the advancement of better cockpit management has undoubtedly played a significant role in mitigating the highly variable landscape of risk that coexists with the everyday operations of today’s airlines.
Aviation Safety – A Lesson in Health?
The aviation industry has become inherently safer today, not simply because those that fly the aircraft or maintain them are more highly skilled, but because everyone in the industry has become smarter about the risks involved. This has evolved out of a commercial imperative which has driven the industry to ensure public confidence. This plus the dedication of a number of safety-minded people in the industry aided to some extent by governmental bodies willing to assist both financially and through regulatory regimes has accelerated the process compared to some other industries.
The public don’t usually get the choice as to whether they wish to become a patient in the same way an airline passenger can choose to fly. Therefore public rather than commercial pressure drives the need for improved safety. In many cases the public are not aware of dangers that exist in the health industry unless there is a major litigation case, whereas an aircraft accident receives wide media coverage in the tabloids and on television and radio.
Whilst seemingly poles apart, the hospital and aviation industry share a similar risk profile. Both are relatively assiduous industries vulnerable to complacency and human error factors associated with hierarchy, decision making and communication; outcomes of poor safety control can pose an immediate threat to human life; and poorly focused regulatory control disconnects and disenfranchises participants.
While safety is the responsibility of every individual, organisational safety is much more complex and cannot be externally managed or applied. A mutual approach by the operator and the regulator is essential, and must filter down throughout the entire organisation to create the ultimate safety platform: a pervasive safety culture.