Another Glimpse into the FAA “Safety Culture”

I just had another long talk with my FAA supervisor that once again highlighted how little the FAA is committed to safety and improving the air traffic system.

We started talking about some relatively new procedures that have resulted in a lot of confusion and resulting operational errors and deviations (air traffic system errors).  An operational error is when two or more airplanes get too close, and a deviation is when an aircraft enters another controller’s protected airspace illegally.

The air traffic system has a lot of potential for human error (it’s a fact that there are human beings in the system making critical decisions and human beings make mistakes).  However, the redundancy built into the system (usually) is intended to ensure that a single mistake doesn’t result in an error/incident or accident.  It (usually) takes a series of mistakes or faults to result in an error.

The entire air traffic system works because of clearly defined procedures for doing business.  But failing to properly follow a procedure can begin a chain of events that could eventually lead to a systems error.

In our discussion my supervisor reiterated the FAA managers’ belief that system errors/mistakes are almost solely due to “performance issues” with air traffic controllers.  Their opinion is that errors occur simply because the employee is too lazy, failed to follow procedure, or otherwise do his job.

Because they believe that, our managers have also stated that it’s possible to have zero operational errors (not make any mistakes).

Of course that attitude is a gross oversimplification and fails to take into many factors that contribute to a systems error, but it’s most certainly the easiest explanation for operational errors.  If a mistake is made it’s simply because the person failed to perform as expected.  Simple, neat and easy.

It’s also an attitude that totally fails to acknowledge human error.

If the FAA isn’t really interested in looking at the root causes of errors, and instead simply writes off those errors to “performance” failures the system will never be improved.

I on the other hand fault some of the procedures and equipment within the air traffic system that actually contribute to human error mistakes.  I believe that those procedures and equipment should be changed/fixed so that the possibility for human error is reduced.

If a procedure is confusing or is causing a lot of errors, then the procedure itself should be examined and possibly changed.  If a computer system is confusing or doesn’t operate properly it should be changed.

Before I got hired by the FAA I worked in a barbecue grill factory tracking parts inventory.  One of the things I vividly remember about that job was the giant industrial machine die presses that they used to bend/create many of the steel parts for the grills.

industrial press1 industrial press2

The presses would take flat pieces of steel and using a ram with a great deal of force press and/or cut them over a die.  The operator would load the machine with the steel blank and then engage the machine.  Once the machine cycle had completed creating the part he would remove the part and stack it or throw it into a bin, and reload the machine.

These machines were big, noisy and scary and when they ran they shook the floor of the factory.  Given the amount of force they generate they can also maim or kill.

Some of the older veteran machine operators were missing fingers from operating the presses years before they had mandated safety features.

Modern presses have safety systems where the operator has to be standing in a safe area and needs both hands to press two separate buttons (separated so that they can’t both be pushed with one hand) to engage the press.  That prevents the operator from having his hands in the operating area of the press or standing in an unsafe place.

The reason I bring up the presses is that if the FAA were running a factory, they wouldn’t have those safety systems.  If an operator lost his fingers in press they would simply say it was due to operator error (a performance issue).

They might send out a briefing item for the operators to read saying simply “if you put your hands there you might lose a finger” but that’s about it.  They certainly wouldn’t take any steps to ensure that the operator couldn’t make that mistake.

That’s exactly the attitude the FAA managers have towards errors within the air traffic system.

Examining the root causes of errors and making real changes towards improving safety within the air traffic system would be hard.  But if they did that it would also make them more accountable for errors as well.

On the other hand blaming individuals (air traffic controllers) is easy.  It also lets those who work in the offices establishing procedures totally off the hook when it comes to procedural and systemic problems.

So much for the just culture/safety culture the FAA likes talking about…


  1. I can’t believe you let that discussion bug you so much that you couldn’t let it go. Nicely phrased argument though.

  2. Letting it go would be easy, and I’m no FAA manager…

    It is frustrating to work for the FAA and actually know that we could do a better job at what we do and still (as an organization) choose not to…

  3. Tell your sup to read Sydney Dekker’s books “The Field Guide To Understanding Human Error” and “Just Culture: Balancing Safety and Accountability”

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