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The Human Factor: Using aviation principles to boost organisational performance, reduce error and get the best from your people
The Human Factor: Using aviation principles to boost organisational performance, reduce error and get the best from your people
The Human Factor: Using aviation principles to boost organisational performance, reduce error and get the best from your people
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The Human Factor: Using aviation principles to boost organisational performance, reduce error and get the best from your people

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About this ebook

How can you improve the way your organisation handles turbulence?

How do you get your people on the same flight path?

What if you could reduce the number of errors made at your workplace by half?


The aviation industry can provide the answers to these questions, and more. Flying commercial aircraft is complex with li

LanguageEnglish
Release dateSep 9, 2020
ISBN9781922391254
The Human Factor: Using aviation principles to boost organisational performance, reduce error and get the best from your people
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Author

Graham Miller

Graham Miller is a Brisbane-based management consultant who spent over 20 years in the Royal Australian Navy's Fleet Air Arm in aviation and management roles, before working in organisational development positions in the public sector. For the past 12 years he has consulted to organisations large and small, in all areas of organisational resilience, to help them get the best from their people. The merging of Graham's aviation background with his consulting experience delivers an engaging and easy-to-read book, providing unique insights into how you can use the principles developed and used in the aviation industry to get the best from your people, optimise your organisation's performance, and build organisational resilience.

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Rating: 3.036036036036036 out of 5 stars
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  • Rating: 3 out of 5 stars
    3/5
    Mild mannered spies ; one is a double agent, an innocent man is poisoned and an unloved dog is shot and of course the patient wife knows nothing.
  • Rating: 5 out of 5 stars
    5/5
    An uncompromising masterpiece depicting the world of espionage in all its mucky glory!
  • Rating: 3 out of 5 stars
    3/5
    Competent example of the genre but nothing here that John LeCarre hasn't done better ... and with a lot more heart. Greene makes us understand the moral ambiguity that haunts "everyman spies" like his drab, middle-aged family man Maurice Castle, but only as an intellectual puzzle. John LeCarre's novels, especially his George Smiley novels, manage to accomplish this but also make the reader feel the anguish of it.If you want Graham Greene's original, fresh and worthwhile take on the intelligence business, read "Our Man in Havana" and give "Human Factor" a miss.
  • Rating: 4 out of 5 stars
    4/5
    My chest hurts. Okay. One thing I like about this book is how his secret agents are neither action heroes or ordinary boring joes like he's trying to deflate the myth and shit. Like, in this book it's just a job, but it's still a really crazy job and they do intense things. Feels accurate.
  • Rating: 5 out of 5 stars
    5/5
    One of the best espionage books I've ever read. Greene (and LeCarre of course) use the genre to write great novels, not great spy novels. His investigations of loyalty, love, race, apartheid, alcoholism...all are fantastic. Well done.
  • Rating: 4 out of 5 stars
    4/5
    Graham Greene expanded my view of the world beyond America. The reader is invited in through the very british/ambivelent catholic soul of the main character and then taken to exotic South Africa where his love crosses racial and political boundaries. My introduction to apartheid which is only one of the political dead ends faced by this secret service bureaucrat as he faces the usual Graham Greene conflicts of faith, loyalty and conscience. Gripping all the way through with the spy intrigue deepened by trying to live with your own soul.
  • Rating: 4 out of 5 stars
    4/5
    This is marvelous late Greene, a spy story made all the better for the self-aware references to James Bond (and the unreality it represents). Counter-espionage with drama and genuine understanding of human psychology and emotion, topped off with the challenge of tackling Apartheid and English race issues. Also worth noting that this Everyman's Library edition is wonderful and worth the hardcover investment.
  • Rating: 3 out of 5 stars
    3/5
    Beste van Greene, vooral door evenwichtige en diepmenselijke karakterisering, als contrast met het onmenselijke van de geheime dienst.Bovendien evenwichtige mengeling van allerlei thema’s: geweten, patriottisme, menselijkheid, liefde.

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The Human Factor - Graham Miller

Preface

A world of ‘errorism’

Errors are a fact of life

The term ‘errorism’ is used throughout this book to describe the naturally occurring human phenomenon of error-making. Errors happen every day, in every industry, business and household, and they often occur when they are least expected. These errors are usually unintentional, most are insignificant, and many go unnoticed. Errors that are noticed and significant are often referred to as ‘mistakes’ or ‘accidents’. Many are seen as unavoidable. As the saying goes, ‘accidents happen’.

We expect errors. We factor ‘margins for error’ into our plans and operations. We accept the concept of ‘human error’. Sometimes high-profile people (Australian cricketers, for example) make televised apologies for their ‘errors of judgement’. As English poet Alexander Pope wrote in 1711, ‘To err is human; to forgive, divine.’

It seems that we live in a world of ‘errorism’. It’s part of life.

Some errors are obvious. An error made on a building site, or in a hospital operating theatre, or when driving the kids home from a ballet lesson, is unmissable, and can result in consequences that will never be forgotten by those affected.

But many errors are not obvious. A poor business decision or a misreading of the market might result in a lost business opportunity or, even worse, a business closure that impacts your livelihood and that of your staff and their families. When information that is common knowledge in the marketing department is not shared with the production department, market share may be lost. These more insidious errors might go undetected or unrecognised – or if they are noted, they may be discounted or rationalised as bad luck, or the result of an event beyond our control.

But what if we could reduce the number of errors that happen? What if we could manage errorism? Imagine if we could reduce by half the number of errors that occur. Half the number of missed business opportunities or avoidable business failures, half the number of house fires, half the road toll, half the number of industrial accidents, half the amount of time spinning our wheels correcting errors. Imagine the suffering, the trauma, the heartache and the wasted time and effort that could be avoided. Imagine the joy and prosperity that could result from this.

We are all fallible

Managing errorism is possible, but it requires a particular mindset. This mindset must first acknowledge that we humans are fallible – all of us. That means accepting that good, competent, experienced, well-intentioned people, as well as the not so good, not so competent and not so experienced people, can all make errors. That includes the professor, the boss with 30 years of industry experience, the world-renowned expert, the diligent master craftsman. It also includes you and me. It means accepting that, no matter how amazing or talented a person is, there is a limit to human capability and capacity. It means accepting that no single person can know enough, about enough things, enough of the time, to be 100% right 100% of the time.

If we adopt this mindset, it would make sense to put into place ‘checks and balances’ (processes and practices) to reduce the chances of errors occurring in the first place, or to help recognise errors when they do occur so that something can be done about them.

The aviation industry

High-risk industries such as aviation know this well. They deal with the potential for catastrophic consequences of error-making on a daily basis.

Over the past 40 years, the aviation industry has pioneered ‘human factors’ programs specifically designed to manage errorism. These programs have helped improve the aviation industry’s safety record. In the past 20 years the aviation industry’s fatal accident rate has reduced by 80%, from 0.5 fatalities per million flights to 0.15 fatalities per million flights in 2016. ¹ As a result, you and I are more likely to come to grief today when driving a car to the airport than when travelling as a passenger in a commercial aircraft.

To say that these improvements have not occurred by accident is true, but it is also ironic. As anyone who has watched Air Crash Investigation on TV knows, every commercial aircraft accident is analysed in detail and the investigation findings are used to improve aircraft design and operations, so that the same thing does not happen again.

Over the years, the findings from aircraft accident investigations have resulted in improvements in aviation technology, automation and, importantly, processes and procedures to address human error and poor teamwork, otherwise known as ‘human factors’.

Human factors

We can learn a lot from this rich experience. The principles underpinning human factors programs developed in the aviation industry have been adapted and applied to other high-risk industries. And surprisingly, these simple principles can be applied to your organisation too; in fact, to any place where fallible humans operate. You don’t have to operate in high-risk industries to benefit from adopting these concepts.

This book will help you manage errorism and build resilience within your organisation or workplace by adopting the powerful ideas, systems and concepts developed within the aviation industry over the past 40 years, no matter what type of industry or area you operate in.

These ideas are used today to safely operate complex commercial aircraft such as the Airbus A380. The A380 is the world’s largest commercial passenger aircraft. It can carry up to 853 passengers, but most airline seating configurations enable passenger loads of around 500, which is still an impressive number of people. It’s a complex machine with a myriad of mechanical and electronic systems. It weighs around 550 tonnes, and flies at nearly 1,000 kilometres per hour, 11 kilometres above the Earth. It is operated by two pilots (and two additional pilots are generally carried on long-haul flights) and a cabin crew of around 20.

Before the aviation industry was severely impacted by the COVID-19 pandemic, at any point in time there could well have been around one hundred A380s flying 50,000 passengers through the Earth’s stratosphere at nearly 1,000 km/h, along with thousands of other passenger jets doing the same thing.

Errors made in this unforgiving environment can be catastrophic.

It turns out that the people who fly, manage and support the A380 (and all other aircraft) are fallible humans, like you and me. They are prone to making errors like the rest of us. The good news is that these people undergo specific training to help them understand the issues around human fallibility, and they learn how to adopt simple practices to manage errorism.

This book outlines how you can manage errorism by adopting aviation’s ‘human factors’ principles. The book shines a light on human fallibility and explores the simple principles that can be applied in your organisation to improve what you do – by countering errorism to build organisational resilience.

So please, fasten your seatbelts, sit back and enjoy the journey.

Chapter 1

Connecting the dots

After Steve Jobs’s untimely death in 2011, I watched a YouTube video of an address he had given in 2005 to a group of new students at Stanford University. Jobs told the students about his short university experience, which only lasted six months before he dropped out, much to his parents’ chagrin. But he elected to hang around the campus for another 18 months, enjoying the social life and attending lectures on subjects that interested him.

Calligraphy was one of those subjects. He learned about fonts and spacing and typography. At the time he never imagined this knowledge would lead to anything productive, but 10 years later, when he was designing the first Macintosh computer, he included all the interesting fonts he had learned about all those years before. These fonts became a hallmark of the Mac. Jobs made the point that when he was sitting in those calligraphy classes, he couldn’t have conceived how those moments would impact his future. It was only in looking back that he could connect the dots. His message to those new students was to follow their heart, even if it led them off the well-worn path, and trust that the dots would somehow connect to deliver the future they were destined to have.

We all have a story. We all have a unique history made up of a string of connecting dots. Our past has led us to our ‘now’ which will lead us to our future. This book is a result of my personal string of connected dots.

Cyclone Hamish

In March 2009, Queensland was battered by Tropical Cyclone Hamish. Hamish started life as a low-pressure system in the Coral Sea near Cape York, at Queensland’s tropical ‘top end’. The cyclone gained intensity as it made its way south through the iconic Great Barrier Reef, and by Saturday 7 March, Hamish was classified as a ‘category 5’ cyclone – the maximum classification for cyclones in the Australian region.

On Sunday and Monday the big storm continued tracking south, staying about 100 kilometres off and paralleling the Queensland coast, generating wind gusts of almost 300 km/h. By Tuesday 10 March Hamish had travelled a long way south, and was off Fraser Island (300 kilometres north of Brisbane) – now a ‘category 4’ cyclone. It was at this point that Hamish decided to turn left and meander its way back to the north. As it did, the big storm seemed to get tired and its fury slowly started to dissipate. A few days later it had subsided to a mere low-pressure system again.

During its journey, Hamish whipped up some enormous seas, even in the state’s south where the huge surf eroded Queensland’s southern beaches. Even as the cyclone was weakening and retreating north, wave heights of 8.8 metres were recorded at Point Lookout on North Stradbroke Island, just northeast of Brisbane.

On the evening of Tuesday 10 March, as Cyclone Hamish was turning left off Fraser Island to start its journey north, a Hong Kong–registered container vessel, the Pacific Adventurer, was just off Queensland’s Gold Coast, gingerly making its way towards the pilot boarding area for its planned arrival into Brisbane the following morning. The seas had become increasingly rough, with 10-metre waves causing the big ship to roll up to 35 degrees. Conditions on board were becoming extremely uncomfortable. None of the off-duty crew could sleep, and those on the bridge could not stand without holding onto something. No doubt the crew would have been looking forward to some respite from the heavy seas once they rounded the northern tip of Moreton Island and entered the sheltered waters of Moreton Bay and, beyond that, the port in the Brisbane River.

However, Hamish was not done with the Pacific Adventurer just yet.

Overboard

Just after 3.00am on Wednesday 11 March, as the Pacific Adventurer was east of Moreton Island, the Captain turned the big ship westwards, towards the pilot boarding area. As he did, the ship rolled heavily to port – to an estimated 40 degrees! The force of this was just too much for the tie-down points holding the containers in place in bay 25 on the upper deck. With a groan, some of the ageing points began to give way. Two containers crashed through the guard rails on the port side and slid into the dark and angry waters below. As the ship rolled back to starboard, more containers tumbled from the deck into the sea. In less than a minute, all 31 containers from bay 25 were lost overboard. ¹

Although the crew was unaware of it at the time, at least one of the containers had crashed into the ship’s side as it fell into the waters below, creating an 18-centimetre gash and piercing a fuel tank. In the darkness, black heavy fuel oil (fuel used by the ship’s engine) started to flow undetected into the sea. It wasn’t until dawn, almost three hours later, that the chief engineer discovered the stream of black oil gushing into the water. Initial reports from the ship indicated that only 20 to 30 tonnes of heavy fuel oil had been lost overboard. Later, however, this figure was revised to 270 tonnes. ²

The big swell pushed the oil slick towards the mainland, and by mid-morning oil had reached the shores of Moreton Island. In the coming hours and days, significant quantities of oil would wash up on beaches along 61 kilometres of the southern Queensland coast, including the pristine beaches of Bribie Island and the Sunshine Coast.

Fishing grounds and tourist destinations were impacted. With Easter holidays only weeks away, Queensland’s hotels and holiday homes, restaurants and local businesses would feel the impacts of Cyclone Hamish. This was shaping up to be an economic, as well as an environmental, disaster.

The clean up

Australia has well-established arrangements for dealing with oil spills like the Pacific Adventurer incident. In line with these national oil spill arrangements the Queensland Government agency responsible for oil spill response, Maritime Safety Queensland, immediately swung into action.

Cleaning up oil can be a tricky business and, prior to the Pacific Adventurer oil spill, it was standard practice that only specialist oil spill agencies would be involved in oil spill response and clean-up activities. Maritime Safety Queensland is one such specialist group, and similar groups exist in Australia’s other states and territories. Under Australia’s national oil spill arrangements, a team of oil spill experts from around Australia (known as the ‘National Response Team’) would deploy to wherever they were needed to assist in managing a spill response. Many members of this team know each other, having trained and worked together. These well-established national arrangements were enshrined in inter-governmental agreements and Memorandums of Understanding. However, the Pacific Adventurer incident changed all that.

The timing of the Pacific Adventurer oil spill was unfortunate – only 10 days out from a Queensland state election. With the election campaign in full swing, the Pacific Adventurer incident was of great interest to a fully mobilised media contingent bored with politician-managed media appearances. The oiled beaches and affected wildlife were within easy reach of helicopters and media crews, and the graphic images generated immediate public interest and significant national and international attention. The media were keen to know how the incumbent Labor Premier, Anna Bligh, would respond just 10 days out from an election where she was attempting to become Australia’s first female Premier elected in her own right. (Bligh had assumed the Premiership from Peter Beattie following his mid-term retirement in September 2007.)

What would the Premier do?

As the scale of the incident became apparent, Anna Bligh declared a ‘disaster situation’ which ‘activated’ Queensland’s disaster management response arrangements. This was the first time in Australia’s history a state’s disaster management arrangements had been activated in conjunction with Australia’s national oil spill arrangements. This decision mobilised Queensland’s disaster management agencies to assist Maritime Safety Queensland and the National Response Team. This included local governments, police, emergency services and other state government departments, none of which were particularly familiar with marine oil spill response procedures. This presented a significant coordination challenge – everyone wanted to help, but many didn’t know how. In the initial confusion, one local government deployed heavy equipment onto the beaches to scoop up the oil deposits, unaware that the tyres of these machines pushed the oil deeper into the sand, and even more oil would arrive on the next high tide!

Anna Bligh went on to win that Queensland state election, and in the following months the oiled beaches were cleaned up. However, the unprecedented decision by the Premier to declare a disaster presented a new paradigm for oil spill response in Australia, a concept which has since gained traction nationally.

Reviewing of the Queensland Government response

I remember the day of the Pacific Adventurer oil spill. I was facilitating a disaster management discussion exercise in Brisbane for 50 transport sector stakeholders, and I recall a senior executive from Queensland Transport notifying the group of the incident mid-exercise. He and other senior government participants had to leave the room periodically during that day to take phone calls.

Although I didn’t realise it at the time, I would become quite familiar with the events that unfolded over the coming days and weeks.

My career as a management consultant was in its early stages when this incident occurred. I had previously worked in the Queensland Government and had become familiar with Queensland’s disaster management arrangements. I also knew people in Maritime Safety Queensland. I assume it was this combination that led me to receive a call from Maritime Safety Queensland a few months after the Pacific Adventurer incident, seeking my services to undertake a review of the Queensland Government response. This review involved interviewing stakeholders, exploring assumptions and synthesising findings, and in November that year my report was tabled in Queensland Parliament by the Premier.

Not again

Thankfully, significant maritime incidents are rare, so like many people I was surprised to read in the newspaper the following year (only 13 months after the Pacific Adventurer incident) that a Chinese bulk coal carrier, the Shen Neng 1, had run aground on the Douglas Shoal in the Great Barrier Reef. The Shen Neng 1 had been taking a ‘short cut’ and came to grief in shallow water due to ‘human error’ caused by a number of factors, including crew fatigue.

This stricken, fully laden ship presented a significant threat to Queensland’s marine environment. The potential damage of the Shen Neng 1 incident was significant. At one point it was feared that the vessel would break up, spilling tonnes of coal and oil into the waters of the Great Barrier Reef. Once again, Premier Anna Bligh declared a disaster situation, which activated Queensland’s disaster management arrangements to support Maritime Safety Queensland and the national oil spill arrangements.

Fortunately the Shen Neng 1 did not break up and spill its cargo onto the Great Barrier Reef. A salvage team worked hard to maintain the integrity of the ship’s hull, and after a number of weeks the coal on the Shen Neng 1 was meticulously transferred, over a number of days, to other vessels. The Shen Neng 1 was eventually re-floated. The incident resulted in the loss of only three tonnes of heavy fuel oil into the waters of the Great Barrier Reef, which dissipated naturally; none of it reaching the mainland. Even though the ship caused significant scarring to the Douglas Shoal, embedding noxious lead paint in the coral, all in all this incident could have been much worse.

As occurred the previous year, in the weeks following the incident I received a call from

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