Lessons from Twelve Years in Pursuit of Zero

We often see a visual display of the safety performance metric “days since lost time incident” in workplaces. It’s common where the job requires physical labor or where there is injury risk. The more days, or the longer interval between lost time incidents, the better. The ultimate goal is zero accidents or zero lost time incidents. Since it’s hard to count to zero, the “days since” gives people a positive metric to track on a daily basis.

Recently, the U.S. domestic airline industry achieved a stunning feat: twelve years without a fatal crash. This amounts to more than eight billion passengers traveled without such an incident, representing an 80% improvement. This 12-year journey is detailed in a Wall Street Journal article titled The Airline Safety Revolution.

How to Think About the Pursuit of Zero

The pursuit of zero is another way of saying the pursuit of perfection. For some operations, perfection means adding more value, new features, becoming faster, or becoming more accurate. In airline safety, perfection is the result not of adding but of taking away. Ambiguity, complexity, and complacency are abundant contributors to risk.

Whether or not an individual or a leadership team decides to pursue perfection has a lot to do with how we think about the pursuit of zero. A quote in the article from Randy Babbitt, former head of the FAA from 2009 to 2011, is revealing. As president of North America’s largest pilots union, he was also an early supporter of many of the safety initiatives. And yet it seems he never expected to be able to achieve zero. “The magnitude of the improvement has far exceeded my expectations,” he said, adding, “It’s almost like buying a lottery ticket for 10 bucks and winning the jackpot.”

Do we really think perfection is achievable? Or is it only a slogan? What are the tradeoffs? How close to zero can we get before it becomes too expensive to pursue? Too often we get lost worrying about these points and never get started. Even if it’s only a small group of leaders who believe, it’s essential to start with a belief that zero is achievable.

Was it a lottery ticket? A lucky streak of eight billion safe passages? Or was there a deliberate method?

How the Airline Industry Got to Zero

The article describes many features and practices of this airline safety revolution. Continuous improvement practitioners will find them familiar. These include having a sense of urgency or impending crisis. Another is having a human-centered, or customer-focused, mission. This initiative started, as many do, with a small group of highly committed and influential leaders. It required engaging a wide range of  stakeholders, such as the regulatory, operation, maintenance, service, and other functions.

The industry agreed on a common goal and approach, but made participation in the incident reporting program voluntary. Government and industry experts extracted safety lessons by reviewing large volumes of flight data and tens of thousands of reports written by pilots, mechanics, and air traffic controllers.

Although a decade of technological advances contributed to better safety, many high-impact improvements in the pursuit of perfection required zero investment, other than time for training, communication, and documenting standards. Some improvements were as simple as a pointing and calling practice. For example, both pilots point to the cockpit instrument, say out loud that they entered or read the correct settings, and double-checked each other. It’s almost shocking to think that this is such a recent innovation.

First, Make It Safe to Speak Up

As with any simple but fundamental change to our ways of working, the airline safety revolution started with a transformation of trust. This may be as simple as sharing information between organizations, agencies, and representatives. The FAA pledged that good-faith mistakes and procedural violations would not result in enforcement actions. Senior pilots had to accept that junior pilots may point out their errors.

The article quotes Ray Valeika, former head of engineering and maintenance at Delta. As Ray explained, “We actually patted people on the back” for pointing out mistakes, but also stressed that people could lose their job for hiding mistakes from management. Even when pursuing perfection, professional and psychological safety come first.

From Voluntary Practice to Global Best Practice

Humans are capable of designing, building, and operating technologies capable of doing things our ancestors could barely have imagined. Yet our ability to manage ambiguity, complexity, and risk has not kept pace. These are still constrained by our the biases, cultural norms, and how we respond to social and biological cues. As we build ever more fast and powerful technologies, we need to put equal effort into building systems to operate these in safe and human ways.

While far from perfect, the safety management system practiced by U.S. airlines is now a global best practice. Domestic airline industries around the world are learning from and attempting to copy it. For many, the pursuit of zero is just a rallying cry for better performance, not a decades long life-or-death struggle. Whatever may be the case in our individual situations, we can learn lessons from the remarkable 12-year journey of airline safety.

1 Comment

  1. Andrew Wagner

    June 3, 2021 - 12:04 am
    Reply

    Very proud of the *tiny* part that I have been able to play in this story over the past nearly 20-years!

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