Just a few-ish years ago, myself and some other young student aviators departed Naval Air Station Jacksonville, Florida in our T-45 “Goshawk” training jets to do the final phase of jet school which would require us all to land – in a sufficiently safe and precise manner – multiple times aboard the USS George Washington, at the time churning off of the north Florida coast. Known as “Carrier Qualification” or “CQ,” it was the final right of passage to earning your wings as a Naval Aviator.
In a formation of four airplanes, we arrived overhead of the ship after about 30 minutes of flying over the open Atlantic. My first thought in looking down on what seemed to be an impossibly tiny slice of metal to land on was both, “I’m petrified” and “I’m ready.”
Let’s first look at the principles of High Reliability:
1) A Preoccupation with Failure: a hypersensitivity to error, both past, present, and unanticipated.
2) A Reluctance to Simplify: the perpetual examination of the complexities and dynamics associated with systemic breakdowns.
3) Sensitivity to Operations: the integrity of the business line(s) is/are paramount.
4) A Commitment to Resilience: an understanding that failure or challenge can occur and when it does, operations can continue.
5) Deference to Expertise: the depth of knowledge is more important than the position on the org chart.
All of these principles add up such that organizations must accept that errors and disruptions will occur at any time and those errors must be managed so that first, errors do not compromise desired outcomes and second, every effort must be made to ensure that the error never occurs again. These principles form the foundation for safe operations in complex and high-consequence environments.
The Joint Commission – the quality accreditation organization for a significant portion of the nation’s healthcare systems – outlines a straightforward methodology for implementing High Reliability practices in pursuit of operations excellence. The framework consists of three elements:
1) Leadership Commitment.
2) A Pervasive Safety Culture.
3) Robust Process Improvement.
The framework forms a feedback loop in which organizational leadership promotes an environment that cultivates effective safety practices while empowering employees or groups within the organization to have a voice for change or betterment of the organization.
Most important, the first point in the framework does not say, “Leadership Approval” or “Leadership Encouragement,” etc. It says, “Leadership Commitment,” which implies an enduring effort to improve the organization. This long-term focus is critical to any High Reliability effort. Without it, it will fail.
In 2004, the United States Marine Corps experienced one of its worst years in aviation safety. There were 18 Class A aircraft mishaps, where a Class A is defined (in 2004) as aircraft damage exceeding $1 million, loss of life, or the permanent total disability of a service member. Despite it being a time when operations in Iraq and Afghanistan were underway, many of these incidents had no connection with operations overseas. In response, the leadership of Marine Aviation put into place sweeping reforms and initiatives to rebuild the safety culture and drive down these mishap trends. By 2009, Marine Corps Aviation operated with record-low mishap rates even with almost a decade of flying missions in Iraq and Afghanistan.
So how did a bunch of young and relatively inexperienced flyers bring their training jets, moving at around 120 miles per hour, aboard an aircraft carrier safely and with the desired outcome of completing the event to finish Flight School?
More to follow…
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