TECH LOG The COVID-19 crisis offers us a chance to consider a new view of safety, driven by an understanding of complexity and systems operation By Captain James Burnell, easyJet CC member imes do not get more uncertain than now, and this statement stands in the context of safety, too. During the coronavirus pandemic, the operating environment for pilots could have changed in all sorts of ways from air traffic control, airports, passenger handling and, especially, current line flying experience. This is the very definition of a complex situation. The addition of Safety II thinking (more of which later) is in its infancy in airlines, and I would argue that this leaves most airlines inadequately prepared to meet the complex and uncertain safety challenges ahead. The linear cause-and-effect scenarios envisaged and the plans for controlling critical risk being devised in airline safety departments around the country could, in no way, conceive of all the possible outcomes from this unimaginably difficult situation. For decades, we have been focused on reducing errors and putting in controls to stop accidents. This approach has, of course, served us well, but I believe it is time to start the dialogue of change towards adding a new view of safety, driven by the understanding of complexity and systems operation. Many of you may have heard of Safety I and Safety II. Safety II also goes by several other names: Safety Differently, New View of Safety, and Resilience Engineering are the main ones. This new way of looking at safety does not aim to replace the old ways, but should be a natural extension of the amazing work done to date. These ideas have primarily been built from a greater understanding of complexity and systems theory whole disciplines in themselves, but both designed to provide better ways of understanding and interacting with our world. In very basic terms, Safety I is the study of reducing accidents by examining past accidents, the anticipation of future safety issues and their prevention by control of risk, or as seen in the graph above stopping system-performance degradation becoming an accident. Safety II focuses on building resilience around the system, so that when degradation does occur, it has capacity to absorb errors and failures, and continue without incident; in other words, the system boundary gracefully extends. Looking at the graph, Safety II aims to move the green line of system operation to the right, and away from the accidents and incidents box. I feel nervous that such a brief explanation of Safety II cannot do justice to these powerful new ideas. This is in no way representative of their potential when applied to the many areas of our operations, from safety management to organisational performance, and from HR processes to human performance. The Log hopes to bring you many articles to build this understanding and draw these new ideas into regular use. In the next issue will be an article by Adam Johns, a former safety specialist who helped initiate Cathay Pacifics journey into the New View. Back to safety in a time of uncertainty. Normal operations are complex by nature, so safety is most often an emergent property and, as such, can rarely be anticipated in advance of an event. This also means that the real safety experts are those most familiar with the system in our case, current line pilots. Modern safety management does not tell workers how to be safe, but asks them what they need to stay safe. As a result, safety in a system is now measured as the ability of the system to absorb errors and failures or, in resilience engineering language, graceful extensibility of the system boundaries. From this description of safety, the importance of building capacity into our systems should become more obvious, especially in times of uncertainty. To give you an idea of what to aim for when trying to improve resilience, the headings below are just some of the topics produced by current research into highly reliable organisations: Diversity of opinion when planning operations (safety reps and line pilots in the room) Keep the discussion going (do not stop improving just because everything is going well) Ability to say stop (workers need to be comfortable to stop the work) Deference to expertise (experienced workers or subject-matter experts) Constant improvement (monitoring in real time and improving based on feedback from the front line) Reciprocity throughout the organisation (getting rid of silos) For decades, we have been focused on reducing errors and putting in controls to stop accidents Focus of Safety I and Safety II Focus of Safety II: everyday actions and outcomes risks as well as opportunities Focus of Safety I: accidents and incidents Safety performance failure Highly reliable and resilient safety performance There is another component of systems that the airlines need to focus on and support. Creating the perfect operation is impossible, and the glue that holds together these systems is the adaptive nature of the human component. In normal operations, pilots and other workers are a natural form of adaptive capacity but, in a time of uncertainty, this could lead to another issue. Experienced operators (not just pilots) may have been covering decades-old system flaws that have gone unnoticed in daily operations. As we emerge from lockdown, this experience and ability to adapt will have been eroded, and could create issues large and small. Such issues are completely unpredictable, so our focus and that of the airlines should not only be on adding graceful extensibility, but also on supporting the adaptive capacity of the workforce. This can be done by: Listening and reacting fast to information flow from the front line Asking the workers what they need to stay safe and healthy Removing rules that constrain workers and trusting their ability to think critically The ability to create resilience and adaptation in our organisations is primarily built around the managements trust in individual workers to use their natural abilities of critical thinking. Collaboration with the workers and their representatives, such as safety reps, is vital to allow the organisational adaptation that airlines need to operate in the uncertain environment. In this new world into which we are all about to emerge, I predict that the concepts of resilience and adaptation will have to become the mantra in every part of any successful organisation. You can see that the world system, and the smaller systems within, have had little extensibility and adaptive capacity to date, as evidenced by almost everything grinding to a halt. We now see world leaders, company bosses and almost everyone else frantically trying to build resilience and adaptation into their systems so they can safely restart and maintain their operations. All too often in your own airline, you have seen management touting the optimisation of the organisation as maximally efficient, minimum cost, doing more with less. I would argue that the time has come for us to see optimisation not only as being maximally efficient, but also as having the ability to gracefully extend the boundaries of our systems and adapt in the face of uncertainty. If nothing else comes from this crisis, we should learn that the current definition of optimal does not serve its purpose and needs to be changed. In summary: the COVID-19 crisis can be seen, in some ways, as a positive opportunity for us to learn, grow and improve. Airline management, by necessity, will have to put trust in its workers ability to adapt and innovate, and needs to learn from this experience. Decades of rules may be stripped away, and we should consider their value when returning to normal they may have been constraining adaptation, resilience and organisational learning, to name but a few things. During and after, our systems could be studied in ways that we could not have conceived of at any other time, but we must recognise that the metrics we currently collect may now be meaningless. I believe that, if we keep perspective among the understandable fear, we might have a great opportunity to rise from this crisis stronger and more resilient than ever. Our focus should be on extensibility and supporting the adaptive capacity of the workforce