Risk Mitigating Debrief

Huge strides have been made in improving safety through risk mitigation/management by implementing Human Factors techniques. Most of this improvement is through operational TEM strategies for future mitigation and real-time management. Ultimately, a tool is needed that conforms to a Continuous Improvement (C I) model that will drive safety. Continuous Improvement requires the ability to asses past behavior and drive future improvement.  Let’s look at an operational debrief that meets that criteria.

In their postflight procedures, most airlines incorporate a debrief requirement. The obvious goal is error identification, with a secondary goal of error reduction. We do well at error identification, but will identification alone, provide error reduction? The answer is no! Merely identifying the error, brings us no closer to future error avoidance.

Error analysis shows us that causality can be two or three stages removed from the error. We must make causality identification our primary goal, if we hope to reduce errors. Clearly, in many cases, causality is not obvious. In fact, it often hides behind behavioral masking.  Behavioral masking is where we see a miss-applied behavior that superficially describes an error. It is easy to point to a behavior and believe you have identified the error. Problematically, if you don’t continue past the behavior to correct the foundational causality, the behavior will be repeated.

How do we provide the crew with a simple and operationally functional way to address causality and error reduction?  Some airlines use a “Safety, Legality, Standard” debrief format. Let’s use that as an example and explore ways to make it functional.  Typically, the Captain asks the F/O, “Were we safe? Were we legal? Were we standard?” If the flight was uneventful, as most are, the answers are “Yes, Yes, and Yes!” and the debrief is over. But, the question is, were there areas for improvement during that flight? And the answer to that question is unequivocally, yes!  We, as humans, will always make errors. We are incapable of perfect performance in a true sense. We can set standards of performance that we can meet perfectly, but we can never be perfectly standard in all things.  So, on that uneventful flight, how do we mine the event for the nuggets of value that will yield long-term performance improvement?

By taking the above debrief format, and converting it to a causality based format, improvement, from a C I model, begins to take shape.  Applying a priority structure to the debrief, captures the most significant error, creating a mitigation strategy based on priority. In the short time available, at the end of the flight, the debrief must be focused and functional.  A good debrief is specific, positive, focused and defines a clear behavior/action for improvement.  To achieve that in a short debrief is the test of operational effectiveness.

A Continuous Improvement model debrief would look like this: Captain: “Were we safe today?” F/O: “Yes”. Captain: “Did we capture any errors that could have resulted in a Safety of flight issue?” F/O: “No”. Captain: were we legal today?” F/O:” Yes.” Captain: “Did we capture any errors that could have resulted in a Legality issue?” F/O: “Yes, remember when you set the PD altitude for the crossing restriction and I had to remind you to arm it? We may have missed that restriction if we missed that error.” Captain: “Oh, yea, what was I doing that distracted me so you had to catch that?  F/O: “You went into the FMS to set the crossing restriction before setting the FCP.” Captain: “Ok, my goal now is to verify all FCP changes prior to moving on to any other duties.”

Does the short exchange above meet the requirements of being “specific, positive, focused, and defining a behavior/action for improvement”?  First, by using a prioritization model, we move from the most serious criticality, safety of flight, down to the lower criticality of legality of flight. There are no errors captured regarding safety, so the next level, legality, is explored. Upon identifying a captured error regarding legality, the debrief stays focused on that issue until a positive outcome is developed. Good CRM is reinforced through the F/O involvement in error identification and analysis.  Mentoring occurs when the Captain verbalizes a corrective behavior/action and commits to change implementation.

Having identified causality and mitigated the most serious error through behavior/action improvement, the debrief is over. Standardization is never addressed because the more serious error takes precedence.  Prioritization allows for a short, defined, functional debrief, that crews will be able to practice. This simple 3 step approach will yield great improvements daily.  1) Identify the most serious error (captured or not), 2) Discover why it occurred (distraction, lack of knowledge, etc) 3) Commit to a mitigation strategy.

With a Continuous Improvement debrief, crews will have a true means of error reduction. If each crew identifies one error per flight and mitigates with behavior improvements, the annual safety improvement potential is enormous!


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