Most of the time things go right.
Often we think it’s because our procedures and training are so good. And it is true that good procedures help a lot in situations that could be foreseen.
But there is an underground world that we seem to know very little about. The operations seem to have a lot of inherent Resilience – capability to adapt and to deal with surprises. And many of these surprises could not be foreseen. The first finding in the 2013 report* on Flight Path Management is: “Pilots mitigate safety and operational risks on a frequent basis, and the aviation system is designed to rely on that mitigation”.
We rely on the resilience at the sharp end, but we know stunningly little about it! There are conflicting goals, exceptions and practical constraints. Anticipated difficulties and surprises not covered in the procedures. The continual adaptation and adjustment is so natural that professionals hardly notice it. When we do take a closer look into the everyday operation, many of our assumptions turn out to be incorrect. Resilience at the operations creates a critical safety function, but we don’t really know how.
What you would really like to learn is: how much adaptive capacity is there, and against what kind of surprises? And equally critically: how stretched is that capacity already, due to cost-savings and other continuous optimization efforts? Only then can you estimate your true safety level. And you might be closer to the edge than perceived.
In the modern world of Safety-II, understanding Work-as-Done as opposed to Work-as-Imagined provides the key to enhancing resilience and safety. Once you know what the battle-tested good real-world practices are, you can reinforce them and also make sure the rest of the organization is tuned to resilient practices.
But first you need to start exploring Work-as-Done in your organization!
*Report of the PARC/CAST Flight Deck Automation WG