We are delighted that Professor John Kay has allowed us to reprint this column, first published in the Financial Times, which discusses an important organisational risk:- inability and unwillingness to learn from mistakes.
Having just booked a flight to Berlin in June with
Germanwings, I thought it might be useful to explain why.
Air travel is extraordinarily safe. About 1,300 people died
in commercial aviation accidents last year, the highest figure in a decade.
Almost half of these were victims of the two incidents involving Malaysia
Airlines. Tyler Brûlé has described the fear of flying that led him to abandon
a flight to London after hearing about last week’s Germanwings Airbus crash in
the French Alps. The chances of a man of Mr Brulé’s age, 46, dying in any
two-hour interval is about one in 1m. There is an additional one in 5m chance
of being killed during a two-hour flight. On the other hand, sitting in an
aircraft protects you from many more common causes of death, such as a car
crash or a fall down stairs.
Despite the continued growth in traffic, aviation deaths
have been declining. Improvements in aircraft design have reached a stage at
which it is almost inconceivable that a major incident will be the result of a
mechanical failure. Modern Airbus and Boeing models “fly by wire”, which means
that every action by a pilot is mediated by a computer and most of the time
aircraft literally fly themselves. Chesley Sullenberger’s 2009 “miracle on the
Hudson” landing was an exceptional feat of skilled aviation — but as his Airbus
landed on the river it was the machine, not the pilot, that had selected the
gliding speed and angle.
The dangerous moments on board an aircraft are when the
pilot is overriding the electronic systems. They may do so for good reason but
with bad outcomes, as when the crew of Air France 447 from Rio to Paris
misjudged their response to adverse weather conditions and lost the plane in
the Atlantic; or with malevolent intent, as in the Germanwings incident.
Passengers should worry, not that the crew are not in control but that they
are.
But another reason modern air travel is reassuringly safe is
that investigation into accidents is honest and thorough. Airlines and aircraft
manufacturers do not like the public exposure of defects in their products; but
they have tended to respond by addressing the defects rather than resisting the
exposure. And generally accident investigators have been allowed to do a
thorough job without political interference.
The most notable exception was the attempt by Egypt, under
the dictatorship of Hosni Mubarak, to influence the findings of US
investigators into the loss of EgyptAir 990 in 1999. The passenger jet
disappeared into the north Atlantic under the control, like the Germanwings
aircraft, of a pilot widely thought to have been suicidal . And the full truth
of the downing of Malaysia Airlines MH17 over Ukraine is never likely to
emerge. But when French President François Hollande, German Chancellor Angela
Merkel and Spanish Prime Minister Mariano Rajoy travelled to the crash area
last week, they went to show concern and establish what had happened rather
than to deflect blame.
This is the behaviour we are entitled to expect in any
industry: but it is not what we generally see. The bodies that regulate drug
safety do not enjoy the same protection from lobbying as air accident
investigators. And so the pharmaceutical industry has largely lost the public
trust achieved by the “just culture” of the airline industry, which is more
concerned to encourage openness than to attribute blame.
And the contrast with finance could hardly be greater. It is
unimaginable that we might have had a dispassionate investigation of the
financial crash of 2008. Nobody died in that crash — but to avoid mistakes in
the future it is first necessary, in any given situation, to undertake honest
assessment of the mistakes of the past. That is why our planes are growing
safer and our finances are not.
First published in the Financial Times on 1 April 2015.
© John Kay 2015 http://www.johnkay.com
No comments:
Post a Comment