Safety Management in the Aviation Industry and Its Trends
According to a report by the Japan Aircraft Development Corporation (JADC), the number of domestic and international passengers in Japan in 2018 was 127.4 million in total (roughly the same as Japan's population).
Also, the number of deaths due to traffic accidents in Japan in 2018 was 3,532, but the number of deaths due to passenger aircraft in Japan in 2018 was 'zero', and there has not been a single fatal accident involving a Japanese airline in approximately 35 years since the JAL jumbo jet crash in 1985 (excluding the Japan Airlines Flight 706 accident in June 1997).
The figure below shows safety by mode of transport, and even just comparing these numbers suggests that passenger aircraft are quite safe.
The reason passenger aircraft are safe is not only because they are safe in themselves, but because the entire mass air transport system is built on the premise that 'humans make mistakes'. This time, I will introduce the concepts and know-how related to safety management in the aviation industry, as well as its trends.
1. Trends in Hull Loss Accident Rates
However, once an accident occurs, we are deeply shocked by the number of victims and the severity of the accident site.
The figure below shows statistics on passenger aircraft hull loss accidents that occurred worldwide between 1959 and 2018, and the red line represents the accident rate (how many accidents occurred per 1 million flights).
Looking at this, we can see that the accident rate decreased dramatically in the first 10 years from 1959.
Until the 1960s, when the B707 and DC-8 were mainstream, the accident rate was '40'. When it changed to the B727 and DC-9 in the mid-1960s, it halved to '20'.
Then, when the B747 and A300, etc., were introduced in the 1970s, it decreased to '5', and when the B767 and B777, or A310 and A320, etc., became mainstream around 2000, it reached '1', and in 2019, the accident rate reached '0.15'.
The first 10 years, when the era of mass air transport began, saw frequent accidents because it was a dawn period when aviation technology was underdeveloped.
However, by transitioning to new aircraft models that incorporated various improvements and countermeasures learned from accidents, and by advancing various support equipment and rules and integrating them into the system, we were able to achieve the safety mentioned at the beginning.
However, even now that aviation technology is sufficiently developed, why does the accident rate never reach 'zero'?
2. Human Factors
The table below shows the transition of aviation accident factors since the 1950s. Looking at this, it can be seen that human factors have consistently accounted for the majority from the 1950s to the 2010s.
Among human factors, the reality of what is called failure is operational errors or judgment errors arising from complacency, misidentification, assumptions, oversight, miscommunication, etc., in other words, human error. The reason the accident rate does not reach 'zero' is because of this.
3. SHELL Model
Something indispensable when talking about human error is the 'SHELL model'.
The original model was proposed by Frank Hawkins of KLM Royal Dutch Airlines in 1975. In considering aviation safety, he advocated that the following elements are important: S: Software (rules), H: Hardware (equipment), E: Environment (environment), and L: Liveware (self/others). (In later years, M: Management was added to surround the original model, as it became necessary to appropriately manage and operate all elements.)
What is important is the perspective of not only examining each element of SHELL individually, but also how to prevent errors that tend to occur at the points of contact (interfaces) between each element and yourself, who is at the center of the diagram. If the jagged parts of the diagram do not mesh well, it leads to human error.
I will describe the overview of each of these elements and the points to be careful about in the interface with yourself.
S: Software (rules)
This includes all laws, regulations, manuals, and checklists related to the operation of passenger aircraft, such as international treaties, aviation laws, company regulations, airfield regulations, maintenance regulations, and flight manuals.
The aviation industry has enhanced the safety of the entire mass air transport system by establishing new systems, revising existing rules, or adding and replacing procedures whenever safety defects are found.
However, no matter how perfect the rules are, they are meaningless if the parties involved do not correctly understand and comply with them.
In particular, pilots must never be in a "hit-or-miss" situation, even once in a hundred times, and are required to have strict adherence to basics and a spirit of compliance (except in emergencies).
H: Hardware (equipment)
This includes the airframe, cockpit controls, computers, radios, and other equipment.
The aviation industry has enhanced the safety of the entire mass air transport system by repairing existing systems or upgrading to new airframes and equipment whenever safety defects are found. In particular, GPS and autopilots have significantly reduced the burden on pilots and contributed greatly to safe operations.
However, no matter how excellent the equipment is, it must be positioned, shaped, and designed to suit human behavioral psychology.
In fact, there have been cases where aircraft were put in danger because the position or shape was similar to another device. Even with a simple switch, the difference between pushing it down from above or flipping it up from below to turn it "ON" can cause human error.
E: Environment (environment)
This includes the working environment inside the aircraft (room temperature, air pressure, oxygen concentration, lighting, storage, etc.) and the natural environment surrounding the aircraft (temperature, air pressure, wind, weather phenomena such as clouds, rain, and lightning, day/night, etc.).
With the advancement of aviation technology, the habitability and convenience inside the aircraft and the durability of the airframe have improved dramatically. In addition, the development of various systems to support operations has made it possible to grasp bad weather areas that affect safe operations more accurately and in detail.
However, for example, when flying with large attitude changes in an environment such as flying in clouds where the outside view is not visible or night flying, pilots are prone to spatial disorientation (vertigo).
In this case, if you know to "thoroughly follow the instrument panel indications without being misled by your own abnormal sensations" or "hand over the control stick to the other pilot," you can prevent the passenger aircraft from falling into an abnormal attitude.
Also, another important thing is to "avoid entering dangerous natural environments as much as possible."
The flight manual stipulates as a pilot's code of conduct that "safety must be the priority, and at the same time, punctuality, comfort, and, if possible, economy must be considered." However, in the captain's mind, conflicts easily arise between the duty (task) of transporting passengers comfortably and on time, the saving of expensive aviation fuel (cost), and the bad weather areas (risk) that stand in the way on the route.
And in the midst of this conflict, it is possible that the risk in the natural environment is underestimated due to being too conscious of tasks and costs, exposing the aircraft to danger.
L: Liveware (self/others)
The inner "L" is yourself, and the outer "L" is everyone other than yourself involved in the operation (others), such as co-pilots, cabin crew, air traffic controllers, aircraft maintenance technicians, and flight dispatchers.
As mentioned earlier, the reality of human error is operational or judgment errors caused by overconfidence, misidentification, assumptions, oversight, miscommunication, etc. Three forms can be considered: errors by yourself alone, errors by others alone, and errors that occur in communication between yourself and others.
Initially, the aviation industry placed importance on maximizing individual ability (see "4" later). In particular, they attempted to overcome human factors by fostering what is known as a "one-man captain", a captain with absolute dignity and superhuman knowledge, skills, and judgment.
However, the aviation industry realized that no matter how excellent a person is, there is a limit to individual ability, and it cannot be overcome by that alone. In particular, since a lack of communication makes it difficult to notice errors by yourself or others alone, the importance of communication was reconsidered.
Then, Crew Resource Management (CRM: Crew Resource Management), which attempts to overcome human factors by loosening the conventional authority gradient and fostering an atmosphere where people call out to, notice, and point things out to each other, was introduced from the latter half of the 20th century (see "5" later).
4. Qualities required of a pilot
This may be slightly off-topic, but I will talk about the "qualities" required of a pilot that are not unrelated to safe operation.
Pilots are required to have a lot of "knowledge" necessary for operation, "skills" to fly the aircraft accurately, a healthy "body", and a high total balance.
However, that is still not enough; one must acquire the "qualities" necessary as a pilot, gain experience, and cultivate "judgment". The table below illustrates the "qualities" that a pilot should acquire.
Most aspiring pilots who see this will likely show a rejection reaction, saying, "No, no, this is impossible..." However, it is essential for young people aiming to be pilots to start with a reform of their own consciousness.
"It's impossible for me" is just a mental reaction. Let's calmly consider the fact that these qualities are by no means innate, and those who appear to be able to do them now were, without exception, "people who couldn't do it at first".
And one must resolve that such qualities must be acquired in the process of becoming a pilot, and engrave in one's heart that "there is no way to acquire them other than through daily mindfulness and the accumulation of practice."
5. Crew Resource Management (CRM)
Next, I will talk about the concept of safety management as a team and methods for improving communication skills.
CRM is a concept developed in the aviation field that attempts to ensure safe operation by effectively utilizing all available resources in an environment where usable personnel and information are limited.
At a workshop held by NASA in 1979, various research presentations on human factors were made.
At that time, it was recognized that communication between crew members, teamwork, and leadership were deeply involved, and the term Cockpit Resource Management was used for the first time.
Initially, as the name suggests, it was intended to limit resources to the cockpit and promote cooperation between pilots and flight engineers.
However, in the 1990s, the scope of resources expanded to include various occupations and departments involved in operations, such as cabin crew, air traffic controllers, aircraft maintenance technicians, and flight dispatchers, and it gradually spread throughout the world as Crew Resource Management.
(1) CRM skills
CRM presents the skills and elements shown in the table below as qualities that pilots should acquire.
(2) Principles of accidents
And "Heinrich's Law" and the "Swiss Cheese Model" are often used to explain the principles of accident occurrence.
Heinrich's Law
A law proposed by Herbert Heinrich of an American insurance company, which states that behind one major accident or disaster, there are 29 minor accidents or disasters, and 300 near-misses (incidents that did not lead to an accident but caused surprise or alarm). It emphasizes the necessity of eliminating near-misses to prevent accidents and disasters.
Swiss Cheese Model
A concept regarding safety management proposed by British psychologist James Reason. Organizations implement various measures to prevent accidents, but no measure is perfect (the holes in the cheese represent the incompleteness of the measures). Therefore, different types of measures are applied in multiple layers, but even this cannot overcome incompleteness, and it illustrates that when certain conditions overlap (the holes align in a straight line), it leads to an accident.
(3) Threat and Error Management (TEM)
While slightly different from near-misses and cheese holes, in CRM, factors that could develop into errors or abnormal situations are called 'threats.' By noticing and dealing with threats as a team, it prevents development into errors or abnormal situations, a method known as Threat and Error Management (TEM: Threat and Error Management).
In CRM, threats refer to 'factors that complicate flight and induce errors' due to mental fatigue or psychological stress caused by excessive workload, time pressure, or human pressure. Specifically, this includes bad weather, equipment or component failures, airport congestion, low fuel reserves, maintenance work, or passenger delays.
(4) PDCA Cycle / OODA Loop
And, as pilots manage and supervise the normal operation of aircraft through a cyclical activity like the one shown in the figure below, the team's awareness of and response to threats will be woven into this cycle.
PDCA Cycle
W. Edwards Deming gave a lecture at the Union of Japanese Scientists and Engineers, and executives of the union who heard this talk proposed the PDCA. It is a method that attempts to improve operations by not leaving initial plans or executed tasks as they are, but by periodically evaluating and improving them.
OODA Loop
Recently, a method called the OODA loop has been attracting attention. The OODA loop starts by observing the current situation, and because it allows for speedy action through adaptation to change and decision-making, it has the advantage of not being tied to initial plans.
(5) Summary
These concepts and methods have been modified to suit each industry, from the private sector to government agencies and the Self-Defense Forces, and are practiced on various occasions such as training in flight simulators or conference rooms, and briefings before and after flights.
However, this is not the final form. It is a fact that there are negative opinions about CRM.
No matter how much 'equipment' evolves, and no matter how well educational systems like CRM are established to improve 'rules,' 'environment,' and the relationship between 'oneself and others,' the essence of aviation safety—that 'imperfect humans fly a giant lump of iron over the heads of citizens, transporting large numbers of passengers at high speed'—does not change at all.
As long as the most unpredictable human is at the center of operations, one cannot compare the individual pilot's ability with teamwork skills and slight either one.
6. Challenges and Points of Interest in the Aviation Industry
(1) Challenges
Since the end of last year, worrying news related to aviation safety has been scattered. In December 2020, Reuters reported, 'Experts warn of risks regarding the resumption of aircraft operations, with many problems occurring due to long-term suspension.'
While aircraft were grounded due to COVID-19, the report sounded an alarm that as operations resume, pilot skills may decline and maintenance errors may occur. In addition, cases where insect nests have actually obstructed the function of major sensors have occurred, warning that 'the aviation industry needs to prepare for unexpected situations.'
Also, last month the BBC reported, 'Despite a sharp drop in flights due to COVID-19, deaths from civil aviation accidents in 2020 increased from the previous year.'
According to the Dutch aviation consultancy To70, despite the sharp drop in the number of flights due to the impact of COVID-19 (according to Flightradar24, civil aviation operations decreased by 42% last year), the number of deaths from civil aviation accidents in 2020 was 299, an increase of 42 from the 257 deaths in 2019 (including deaths from shoot-down incidents), pointing out that the recovery of skills accompanying the return to normal operations is a problem.
As the wave of the new normal due to COVID-19 surges and work styles and management systems in various sectors of the aviation industry change significantly, I believe that how to ensure aviation safety so that the 'holes in the Swiss cheese' do not align in a straight line (in other words, unexpected conditions do not overlap) to lead to an accident is a major challenge for the entire industry.
(2) Points of Interest
As for points of interest, this may be a bit of a sudden topic, but personally, I am paying attention to the trends in Artificial Intelligence (AI).
Boeing and Airbus are already working on AI-based autopilot technology, aiming for operations with one less pilot by 2025.
What exactly can AI do in the cockpit?
It seems difficult to deal with fatal troubles like the 'Miracle on the Hudson,' and personally, I am skeptical about the realization of an 'AI Captain,' but since AI is good at instantly cross-referencing, calculating, and deep-learning large volumes of data, from the perspective of 'proactivity' and 'accuracy,' I think it could become a quite capable 'AI First Officer'.
AI can see ahead far more quickly than human capabilities.
For example, it can continuously monitor weather conditions on the flight path that change from moment to moment, traffic congestion, and the operational status of aviation security facilities, and present the optimal options to the captain from the perspectives of safety, comfort, punctuality, and economy.
The captain only needs to select from the presented options and press the Execute button. The results will be shared with ground control agencies via a network, and radio communications, which are prone to creating threats, will also be significantly reduced.
If there is an operational error in the procedure, the AI will point it out. Also, by linking with weather radar and the Traffic Collision Avoidance System (TCAS), if there is a possibility of bad weather or proximity to other aircraft, it will issue a warning at a fairly early stage and show a safe and efficient avoidance route.
Furthermore, when an emergency occurs, it is expected to be able to perform auxiliary tasks in many aspects, such as starting the Auxiliary Power Unit (APU), making emergency calls, and suggesting the nearest airport where landing is possible.
If that happens, ultimately, the focus of pilot duties may shift toward monitoring flight status, selecting and executing options presented by the AI, and dealing with emergency situations.
When that happens, how will the nature of aviation safety, such as the qualities that individual pilots should acquire and teamwork skills as described so far, change (or not change)...?
In any case, such an era is already right before our eyes. Although, to maintain the captain's concentration, I would want it to be an AI first officer who can chat with a sense of humor...