AINsight: Safety Differently, by Learning from the Good

 - January 24, 2020, 11:53 AM

For decades, aviation safety practitioners have poured resources into investigating incidents and accidents looking for what went wrong. From that work, lessons are learned with the hopes that those mistakes won’t be repeated, preventing a future tragedy.

Now there is a move afoot to do safety differently. Researchers have flipped the script and are looking at routine flights to learn what pilots are doing right. Early results show promise—apparently, there is a lot to learn from studying success.

Research suggests there are many opportunities to learn from the behavior of those pilots that excel in very complex and dynamic operating environments. One powerful analogy by Leiden University’s Marit de Vos describes our current system as “it’s like we’ve been trying to learn about marriage by only studying divorce.”

This same research supports using both systems to improve safety—each has its own merits. It isn’t a case of “out with the old and in with the new,” but creating a balance of the good and bad. Both systems can peacefully coexist.

The origins of this new concept–called Safety II–is deeply rooted in improving safety in the health care industry. Safety II is a significant mind shift moving from “as few things as possible go wrong” to ensuring that “as many things as possible go right.”

As explained in “From Safety-I to Safety-II: A White Paper” (Hollnagel E, Wears R.I., and Braithwaite J.), “this perspective relates to the system’s ability to succeed under varying conditions.” In this model, humans are a resource necessary for system flexibility and resilience.

For pilots, this concept moves from identifying the occasional human error to finding those practices where, day-in and day-out, crews adapt and adjust to successfully mitigate threats and trap errors.

Recognizing that sound operating procedures are the basis of safe operations, there are those scenarios that take a flight crew “off script” or are displaced from center. The strength of the resilient pilot is to recover from these distractions caused by weather, mechanical delays, system malfunctions, or other factors. Cognition—the ability to learn, adapt, and adjust—is a strength of the human mind. As an industry, we can leverage these lessons and learn from difficult situations where things go right.

The concept of learning from what people do right is catching on. Jon Holbrook, a cognitive scientist at the NASA Langley Research Center, leads a team of researchers that study routine performance and how humans actively contribute by creating safety in complex systems. In a recent article, Holbrook said, “For every well-scrutinized accident, there are literally millions of flights in which things go right, and those flights receive very little attention.”

Resilience has been identified as an attribute that contributes to successful systems, according to Hollbrook and his team at the NASA Engineering and Safety Center. His team has found parallels between resilient systems and humans. “Resilient people can adapt to new circumstances and bounce back from adversity, while a resilient system can adjust its functioning to keep operating despite changes and disturbances,” said Holbrook.  

The mental processes that support resilient behavior is a new frontier in safety science. Holbrook’s project and an additional one at Embry-Riddle Aeronautical University have goals to better understand how humans anticipate, monitor, learn, and respond to challenges and disturbances. One desired outcome is to more deeply understand just how pilot’s behaviors contribute to safety.

It’s a little “tongue and cheek,” but the work of a safety professional is self-defeating. In this perfect utopian universe, there would be no work. It’s a noble goal to have zero accidents, but along with that comes fewer opportunities for discoveries. For the aviation safety community, its healthy to investigate new systems that are proactive and continuously anticipate developments and events.

Let’s give it a shot and celebrate those successes where ordinary flights become extraordinary due to outstanding pilot performance.

Pilot, safety expert, consultant and aviation journalist Stuart “Kipp” Lau writes about flight safety and airmanship for AIN. He can be reached at