Peter DeNucci, ATP AGI UAS
“I noticed that something was off. . . but I was afraid to say something.”
These are dangerous words in many of the industries in which Apollo’s program has been implemented. From the cockpit to the operating room, to the engine room of a fifty-ton locomotive, these words are not what leadership wants to hear after the fact. For a crew to work effectively and efficiently, employees of all tiers have to feel encouraged to speak up about safety concerns. Often, when employees are too afraid to voice their concerns to upper-management, the results are disastrous, tragic, and make for infamous headlines that will haunt a company forever.
At Apollo, we implement internal controls in companies that catch errors before they escalate. Without such internal controls, errors can become at best, expensive accidents or — at worst — fatal tragedies. While these internal controls do act as safety nets for existing errors, it is important to note that the program is so effective in catching employees’ mistakes that it actually prevents most errors from occurring in the first place.
Here’s why.
It turns out that many potentially dangerous situations, known as “at-risk areas” by consultants in the just-culture industry, are noticed by employees long before they come to the attention of leadership.
WHY WOULDN’T AN EMPLOYEE VOICE THEIR CONCERNS?
There are a few reasons why an employee might abstain from reporting to leadership with their concerns.
The employee fears backlash from superiors.
Leadership doesn’t welcome input from anyone working below them.
They are embarrassed that they made a mistake and they don’t want to lose their job.
They are afraid of being seen as a ‘tattle-tale’ or a ‘rat.’
They were acting recklessly when they made the error.
In Boeing’s case, their troubles with culture started with the 737 MAX, when engineers and pilots were pressured to approve the new aircraft despite its inappropriate redundancy for the MCAS.
As a retired US Airways captain, I understand first hand the pressure these engineers are under to meet deadlines and production schedules. While I always felt completely safe flying my Boeing Aircraft (I am type rated on the 737, 757, and 767), the 737 Max was a major blow to the company’s track record.
Airlines first started using the Max in the middle of 2017. Immediately, the new aircraft began exhibiting flight control issues. The MCAS, improperly activated by a single, faulty sensor reading, would pitch the plane nose down. During this malfunction — which was not mentioned in the airplane’s manuals — the pilots could not regain control of the airplane so long as the automated system was on. Fortunately, airline pilots in the United States were able to overcome the forced nose down maneuver due to extensive training with automation failure. However, internationally, this was unfortunately not the case. The pilots of many foreign carriers tend to heavily depend on automation systems. Two 737 MAX flights — Indonesia’s Lion Air flight 610 and Ethiopian Airlines flight 302 — crashed within six months of each other, in October of 2018 and March of 2019 respectively.
The cause of the crashes were MCAS failures, but they signaled a bigger failure in the culture of the company. Somebody hadn’t spoken up, but why?
An investigation would ensue. First, the FAA grounded all defective planes. They mandated software and hardware changes in the Max to cure the MCAS issue. By November of 2019, the investigation had revealed the grim truth. The FAA ordered Boeing to pay a 1.5 Million dollar fine, stating that program management at the company had “exerted undue pressure or interfered with” the crew of employees that were designated to objectively evaluate the safety of the 737 Max.
Also alleging problems with the company’s culture, the Department of Justice charged Boeing with conspiracy to defraud United States government about the safety of the 737 Max. In a settlement to avoid proceeding with the lawsuit, Boeing admitted that production crews had indeed been pressured to approve the aircraft’s MCAS and training prematurely and that employees had purposefully misled the FAA about the new aircraft. Boeing was ordered to pay again — this time, 2.5 Billion in fines and funds for the victims’ families.
The need for culture change at Boeing has never been so dire. Unfortunately, what happened at Boeing is all too familiar to just culture safety consultants like Apollo. When technical professionals (engineers, pilots, etc.) go head to head against managerial leadership, they will usually be outgunned. The two groups have different skillsets and different stressors motivating their decisions. For the five reasons listed above, a dangerous situation can go unnoticed until it’s too late. The new culture must take these differences into account and provide a level playing field where the input to leadership is not only welcome but also encouraged. When Apollo just culture consultants implement culture change at a company, we give management tools to easily conduct a root cause analysis. The outcome, designated by our convenient and simple tools for leadership, will be just and warranted.
In a system with adequate reporting procedures, where there are no unfair repercussions for honest mistakes or pressures to bend to the will of leadership instead of protocol, the employee is no longer silent about errors. Catch that error, and you will avoid the accident.
By consulting with independent experts on just culture like Apollo, Boeing can re-earn the trust of the industry and the public. To arrange a free consultation with Apollo, please contact Peter DeNucci at Peter.DeNucci@safecultures.com.
