The captain woke, opened his eyes and looked around with dawning horror to see that both the co-pilot and the flight engineer were crumpled, asleep in the seats, as the aircraft flew blithely on cross the ocean. Adrenalin pumping, he roused the others as, horrified and with and hearts pounding, they checked their position. With massive relief they realised they were just coming up to their next reporting point and hadn’t taken themselves and their 300 passengers deep into the South Pacific beyond the point of no return.
Not much was said for the rest of the flight as they contemplated the near disaster and the potential end of their careers at best, and their lives at worst. Best to say nothing, then, and a tacit agreement was made. But, over the next few days, the captain’s thoughts kept turning back . . . With the pressures of schedules, rosters, jet lag and family stains, could this happen to others?
That evening he opened his laptop and downloaded a form from the CHIRP website and carefully filled in all the details. He sent the form to the Institute of Aviation Medicine, where it was logged, key dates, names and places changed, and then sent, with about 15 other terrifying incidents to every licensed pilot, engineer, air traffic controller, airport manager, airline executive, medic and legislator on the database.
In a week’s time the magazine had created lively debates in crew rooms, cockpits, control towers, offices, bars and boardrooms. And not one press comment, as the press had committed to keep this experiment in safety self-management out of the public eye. CHIRP stood for Confidential Human Incident Reporting Procedure, an initiative that was part of revolutionising aviation safety by highlighting engineering malpractices, poor management, ego-driven mismanagement, endemic fatigue, the effects of family and work stress. And instead to social controls and normative management – the aviation community self-organised to quickly evolve powerful new practices in the cockpit, destigmatise emotional and human factors, create new syllabi for training and new procedures for communication, call-and-response, challenge and distributed control. This resulted in a significant increase in safety and decrease in incidents.
The big lesson for business, here, is the power of self-organisation and enabling social mechanisms for managing. For aviation safety, like any business or process dependent on high levels of human engagement, discipline, systems and human empathy, it is a complex, systemic challenge – a challenge requiring appropriate solutions that are as simple as possible, but no simpler. And this frequently means complex management approaches. It’s easy to be overly simplistic and seek silver bullets for problems. It’s not always clear what are simple problems and what aren’t. You could say a simple problem is repairing a watch.
A complicated one is repairing an Airbus A380. There are tens – hundreds – of kilometres of wires, circuitry, systems electronics, structures – but all charted and categorised. A complex problem is, well, repairing a marriage . . . anything with human dynamic involved; and even more if linked to complex technology, which starts to reach uncharted and uncharitable waters.
Where human dynamic is involved we reach the realms of voluntarist management – that is to say we have to want to fix things and, unless we can manage to create that willingness, nothing will really get fixed. Authority and rules reach limits here. Both can be subverted by advanced lip service and work – to-rule, the latter approach merely showing how rules, at some level, have to be subverted or ignored in order to work.
Good leadership of voluntary human engagement encourages, emulates, models and challenges. At some levels it creates a positive world-view, in which courage and accountability are key, and service to a boarder professional, client, industry or national community is at the heart. This is the realm at which we start on a personal road to greatness – and it’s not until we realise that we are not and cannot be perfect that we can start to be great.