The Will is as Important as the Wings

The Will is as Important as the Wings Pilots, Pilot Error, and Safety Management Dr. Tony Kern, CEO Lt Col, USAF (Ret) intellectual property of Convergent Performance, LLC. 2014

Four Questions 1. Who is this idiot? 2. What qualifies him to tell me anything? 3. How long is he going to talk? 4. Is any of this testable or can I doze off?

The Lesson of Van Horn, Texas You must never allow the complexities of your personal life, your organization, your technology or your job to overcome your capacity to handle the complexity of the moment. Understanding and mastering complexity is homework, and it is done in advance.

1995 1997 2000 2009 My journey so far. 2011

May I ask you some tough questions? • • • Whose responsibility is it to make you better? Are you as disciplined as you should be? Are you as good as you could be? Are you fully engaged and on task every day? Are your skills and judgment improving or eroding with greater experience? • What kind of role model are you for your peers, and the next generation? • What, precisely, did you learn today that will make you better tomorrow?

Industries I Work With Industries Three Things Functional Areas in Common • Aviation and space • Safety High Risk • First responders • Security (including Cyber) Error Intolerant • Healthcare • Quality • Manufacturing Tightly Coupled • Readiness • Transportation • Culture • Maintenance • Leadership • Human-machine interface • Teams • Employee engagement • Ethics and compliance

“The Past Settles its Accounts…” “…the ability to deal with the unexpected is largely dependent on the structures that have been developed before chaos arrives. The complex event can in some ways be considered as an abrupt and brutal audit: at a moment’ notice, everything that was left unprepared becomes a complex problem, and every weakness comes rushing to the forefront. ” (Preventing Chaos in a Crisis, Lagadec, p. 54)

Overview • Don’t give human error a free pass or ever settle for “good enough, ” as these can be lethal mistakes in our business • Recognize denial or risk, normalized deviancy, and complacency as the threat they are to you • A new approach (SMS) to improving where you are with the resources at hand • A not so gentle nudge to convince you to do so

Fatal Flaw in Our Training It has long been assumed that when you train someone to do something right you are simultaneously training them not to do it wrong. This simple premise is grossly in error and is responsible for thousands of lost lives and billions in lost revenue every year in high risk industries.

Why “Back to Basics” Doesn’t Work “We must, do the right thing and do the right thing right. That's as simple as it gets. "

In 2005, the USAF Chief of Safety stated he doubted the Air Force flight mishap rate can be significantly reduced because there aren't widespread common problems. “It seems the cause is just human error. ” - USAF Chief of Safety, 2005 Source: Air Force Times, Oct 17, 2005, "Aircraft mishaps increase in 2005" p. 16

Conventional Wisdom on Human Error “People will always make mistakes, that’s a given. ” “it’s easier to change situations than people. ” “To err is human. . . it is easier to manage error than to prevent it. ” “Trying to stop human error is a blame and shame game. ” “Errors happen without advanced warning, there is no ‘aura’ beforehand. ” “Human error mishaps are just the cost of doing business. ” “We are forced to work with the crooked timber of human fallibility. ” “Serious human factors experts moved beyond the individual error approach 20 years ago. ” “The weakest link in the cockpit is wearing a headset. ”

Current Approach to Human Error is Primitive PRIMITIVE TRAINERS EEK! HUMAN ERROR! WE NEED ANOTHER THREE LETTER PROGRAM!

Blue Threat Proverb #29 “Only human” is the ultimate oxymoron.

How’s Your Latin? Cujusvis hominis est errare, nullius nisi insipientis in errore perseverare. To err is human, but to persevere in error is only the act of a fool. When we fail to adequately train against the #1 threat our people face, what does that say about us?

So What? I disagree with the conventional wisdom on error. I believe that human error is not inevitable nor “part of being human” any more than cancer is. Errors do happen, but like cancer, most causes can be controlled with little more than enhanced knowledge and serious personal intent. But for this approach to work, we must train error control concepts and reinforce the will to actively employ them in the real world.

Cancer Death Rates by Sex, US, 1975 -2005 Rate Per 100, 000 Men We learned what. Both was causing it, informed Sexes people, and they chose to behave differently Women to protect themselves. How did we reverse this trend with an aging population more prone to the disease? Source: US Mortality Data 1960 -2005, National Center for Health Statistics, Centers for Disease Control and Prevention, 2008.

E v e n t R a t e s Engineering, Technology, Tools and Equipment Safety Systems, Processes, Procedures, Team Training Close Fight Time Personal Behaviors

What is the Blue Threat? The threat we pose to ourselves Remains invisible to many, masked by egos and decades of self-esteem social engineering

“Tony, why do smart, well trained professionals with spotless records, make dumb mistakes and kill themselves and others? ” “Dog” Davis, Lt General, USMC

True, but there’s a bit more to it!

Why do smart, experienced people make dumb mistakes and kill themselves? Not from a lack of skill. There seem to be three primary failure modes: 1. They don’t have the self-awareness to see threat they pose to themselves (blue threat) 2. They don’t see threats soon enough or have strategies in place to counter them 3. They become complacent and lose ownership of their professionalism and decision space

Procedures Planning, Training Checklists, etc. “Key knowledge is in the work” Panic Information Overload Stress induced Error Pacing Span of Control Distraction Attention Apathy Boredom Expert’s Curse Complacency Completely Routine Noncompliance Person Self Awareness, Situation Awareness, Judgment “Key knowledge is in the person” Totally Unexpected Adapted from Jensen, Csikszentmihali, Reason and Kern Adaptive Intellect: Mastery Across Every Level of Challenge

Government OEMs Organization Small Unit You Self-Discipline Safety Management System Standard Operating Procedures Technical Manuals Regulation Routine noncompliance disintegrates systems and teams from within Copyright Kern, Ryan and Agostino, 2005

X Experience Overcomes Error Over time, we make mistakes, learn from them and get better. • • • Learned noncompliance Learned non-accountability Satisfaction with the status quo Learned helplessness in complex systems The error tolerance trap

The Error Tolerance Trap E r r o r T o l e r a n c e Errors are expected but must be corrected and not repeated Student Minor acceptable errors become part of the way we operate day to day Early Career Mid Career No one challenges errors due to experience and position Late Career

Errors Without Consequence? • No such thing as an “inconsequential error” • There are thousands of errors with no short term consequences, but over the long haul, left unchecked, they erode our skills and vigilance, one day extracting revenge • Honest external criticism is so hard to get in today’s world, we must learn the skills of thorough and objective self critique to avoid this fate

The Herald of Free Enterprise (1987) “From top to bottom, the body corporate was infected with the disease of sloppiness. ” Lord Justice Sheen, Official public inquiry

Back to the Sky • Man is not, from an evolutionary perspective, ready to fly, we have forced our way into the sky through technology • We are an uninvited guest there, and would do well to remember to respect our host • When we don’t, and become arrogant and complacent, and bad things happen, it is not a tragedy – it is justice • When we get lazy or cocky – we fully deserve to get our asses kicked

The “Potential” Problem

Why “Good Enough” Really Isn’t

“Mediocrity knows nothing higher than itself. ” Perfecti on - Sherlock Holmes, The Valley of Fear Precisi on Efficiency Effectiven ess Safety Survival Violatio n incident Acciden t Fatality Hazard “Good Enough” The crushing grip of mediocrity and lost potential “The best of the worst and the worst of the best. ” Performance Evolution Ladder – Copyright 1998 T. Kern

Survival How? Best Your Potential Great Better Good Industry Standards Mediocrity Set the bar low enough and everyone is exceptional.

Why “Good Enough” Often Fails There are times when precision is required; when “good enough” isn’t anymore. Maybe only 1 time in 1000, or even 1 in 10, 000 but you don’t get to choose the time of reckoning. You cannot expect to perform under extreme conditions at levels you do not practice for on a daily basis.

Competence without precision is usually good enough to earn a paycheck, but not always good enough to survive. Perfecti on Precisi on Efficiency Effectiven ess Safety Survival Violatio n Hazard “Good Enough? ” incident Acciden t Fatality Performance Evolution Ladder – Copyright 1998 T. Kern

How to Begin Extreme Performance? 2+2 • • Check for competence Train for excellence Practice precision Picture perfection Organizational responsibility Personal responsibility Empowered Accountability is a shared responsibility approach to sustainable organizational excellence.

Practiced Precision • Builds powerful intuition where you begin to notice smaller deviations sooner without conscious effort • Is not only easier than performing to average standards, but also a lot more fun • Leads to authentic self-esteem based on personal accomplishment against self-defined standards

Practice Precision to “See Sooner” Severity Window of Threat & Opportunity Enlarge the playing field Point of and time available Perception to prevent errors. Injury, Fatality or and Detection and seek improvements Mission. Compromise Occurs Onset of Hazard Time

What is “Deliberate Practice? ” “Concentrated and focused practice ‘during the work’ with a clear intent to learn and improve from every experience towards personally defined higher standards of performance. This type of improvement demands negative feedback, which in our self-esteem driven society is damn hard to find. ” – Kern, Going Pro, 2011

Deliberate Practice Doctrine in • Attention to Detail – Every step done right to the best of your ability (this will change over time) • Diligence – Every time, all the time • Discipline – to successfully see and resist temptations to deviate in real time “My true best effort, every time, in full compliance. ”

Why Most of Us Never Achieve Our “True Best” • No one has ever seriously asked us to • No one really expects it • It sounds really hard • We don’t know how to set standards “above the bar” • Average performance seems good enough to get by with • We compare ourselves to others and decide we are OK • Peer pressure and cultural influences shape our expectations and efforts • We don’t see what’s in it for us

Best Effort? What’s in it for me? • • Accurate and powerful intuition Habitual and effortless excellence Authentic self esteem Respect – self and peer Increased margins of safety Direct and remote influence Legacy and no regrets

Closing the Loop: The “ 3 No’s” • Detail • Diligence • Discipline No Excuses No Exceptions No Violations “My true best effort, every time, in full compliance. ”

Why Isn’t This Enough? The world full best of distractions, cultural factors, “My istrue effort, every time, and other performance inhibitors in full compliance. ”

Violation producing conditions Distractions Cultural norms Misperceptions Time pressures Vague guidance For simplified doctrine to be Emotions Poor habits Cognitive bias empowered, these factors must be taken into account, Mission Pressures Ego control and this is where the heavy lifting starts Error producing conditions for true high achievers.

Blue Threat Error Controls Recognition and response to personal error patterns in your life and work setting • • • Error Producing Conditions Violation Producing Conditions Personal/Professional Discipline and Compliance Physiology of Error (including, but not exclusively fatigue) Emotional Control Distraction Control and Attention Steering Vigilance and SA 2 in Highly Repetitive Settings Resisting and Reversing Cultural influences Level III Professionalism 63 specific Blue Threat learning objectives (and counting)

Normalized Excellence “I really had this obsession to keep getting better. I got hooked on the improvement, and the gains that can be made, and the satisfaction that comes from it. ” Danica Patrick, on how she became a world class Indy car racer by age 23

Dude, what does that even mean? Going Pro: The Deliberate Practice of Professionalism

Some leader’s approach to tough professionalism challenges. I’ve just chos en not to see.

May 2010, Washington DC Fifty of the world’s leading experts convened to discuss this critical topic.

Blue Threat Proverb #12 Where intuition fails, intellect must venture. Two years of primary research; over 3, 500 participants; key person interviews; focus groups; quantitative and qualitative

A Very Brief History of Professionalism Let’s start 585 years ago … Rise and fall of the Trade Guilds Master Craftsman Minimum standards Craftsmanfor worker safety and consumer protection Journeyman Novice Apprentice The Rise of the Regulator (i. e. the FAA)

Level I Professionalism: Membership “I’m a pro because I earn a paycheck in this industry. ” pro·fes·sion·al·ism. Noun. A professional is a member of a vocation founded upon specialized educational training.

Level II Professionalism: Compliance to Standards “I’m a pro because I comply with all the standards. ” pro·fes·sion·al·ism. Noun. Professionalism is the adherence to a set of values comprising statutory professional obligations and formal codes of conduct.

Level III Professionalism: Full Engagement “I’m a pro because I am doing all I can to be the best I can and further the objectives of my organization and the industry. ” pro·fes·sion·al·ism. Noun. Meticulous adherence to undeviating courtesy, honesty, and responsibility in one's dealings with customers and associates, plus a level of routine excellence that goes beyond the commercial considerations and legal requirements.

The “Professionalist”. . . seeks the highest standards above and beyond what the regulations require or that expected of them. Professionalist Complier Member These individuals are not only interested in being the best that they can be in their profession; they are interested in improving the profession itself.

Three Levels of Professionalism

Six Areas To Master 1. 2. 3. 4. 5. 6. Professional Ethics (25%) Vocational Excellence (25%) Continuous improvement (20%) Professional Engagement (10%) Professional Image (10%) Selflessness (10%) 24 sub domains and 243 specific behaviors – all with metrics for observation and self improvement

The ONE question to keep asking “What are we becoming? ”

Getting Traction Where do I focus? Evaluating past performance is important. Having a plan to improve is important, but improvement occurs in the present. Past 5 -10% How did I do? What have I learned? Present 80 -90% Practice routine precision. What am I doing? What am I becoming? Future 5 -10% What are my goals? How will I get there?

Personal Performance Management Blue Threat Stop the bleeding from self-inflicted avoidable errors Deliberate Practice Your True Best Activate latent Optimum performance and continuous potentials to “grow improvement where you are”

Be your own hero. In modern aviation, the only true path to greatness is the personal determination to obliterate the minimum standards set by others on the way to achieving your full potential. This requires rejection of cultural norms of averageness, and the willpower to practice higher levels of precision every day on every task.

Questions and Comments?

Back Up Slides “At these best moments a great humility fused with a great ambition: to be only what I was, but to the utmost of what I was. ” - Stephen Spender, World Within World

What Now? Source: Jessica Hagy

The Team Connection: Count the Helmets

Experts See A Different World Contemporary human factors must empower individuals to see deeper into the situation & deeper into themselves to “see a different world” than they do now.

Professional Discipline: The Anchor Point of Professionalism Part 2

Definition: Professional Discipline Pilots of US Airways Express Flight 2495 failed to correctly set flaps while engaged in an extended conversation about sports cars while preparing for take off at an airport in Charleston, West Virginia. Professional discipline is the ability and willpower to safely maintain and employ an aircraft within guidelines, in the presence of temptation to do otherwise. Kern, Flight Discipline, Mc. Graw Hill 1998

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The Compliance Challenge “No man knows how bad he is till he has tried very hard to be good … Only those who try to resist temptation know how strong it is. " - C. S. Lewis Convergent survey data in aviation reveals over 70% of line operators and maintainers admit to “willfully and knowingly” violating a regulation, policy, or procedure within the past 90 days. 76

Mapping Decision Space Purpose Management Guidance Policy Norms Mandatory Discretionary Procedures Techniques Mission Performance Results Source. Blue Threat. Kern. 2010 Line

Good policy and procedures Scope of are organizational regulated action cornerstones. History of system Compliance is an individual cornerstone. Continuous updating of procedures to avoid recurrence of past accidents and incidents Actions sometimes necessary to get the job done Source. Human Error. Reason. 1990

The Human Side of Maintenance Dover AFB Dr. Tony Kern, CEO Lt Col, USAF (Ret) Intellectual property of Convergent Performance, LLC. 2014

Does it Work? • Major aircraft manufacturer service centers had over $40 million in insurance claims over past 8 years due to “technician induced causes” (examples) – One year in to our “Never Events” program, zero claims for the first time in a decade – Quality escapes down by >22% – Safety and quality improvement reporting up by more than 1000% • A newly and truly engaged workforce

“TAP-OUT” • TAP stands for Tools And Panels • Before you leave a plane, tap the nose Intellectual property of Convergent Performance, LLC. 2014