human factors

5-30 Handbook of Aviation Human Factors
Organizational responses to anomaly
Suppression
Public relations
Global fix
Encapsulation
Local fix
Inquiry
FIGURE 5.11
Organizational response to anomaly.
5.8.2 Suppression and Encapsulation
These two responses are likely to take place when political pressures or resistance to change is intense.
In suppression, the person raising questions is punished or eliminated. Encapsulation happens when
the individuals or group raising the questions are isolated by the management. For instance, an Air
Force lieutenant colonel at Fairchild Air Force Base, in Washington state, showed a long-term pattern
of risky flying behavior that climaxed in the spectacular crash of a B-52. Although similar risky behavior
continued over a period of years, and must have been evident to a series of commanding officers,
none prevented the officer from flying, and in fact, and he was put in charge of evaluating all B-52 pilots
at the base (Kern, 1995). When this case and others were highlighted in a report by Allan Diehl, the
Air Force’s top safety official, Diehl was transferred from the Air Force Safety Agency in Albuquerque,
New Mexico, to a nearby Air Force testing job (Thompson, 1995). The attempts to get photos of the
shuttle Columbia during its last flight suffered encapsulation. When questions about the foam strike
arose while the Columbia was orbiting in space, several individuals wanted photos of the potential
damage. For instance, a group of NASA engineers, whose chosen champion was structural engineer
Rodney Rocha, felt that without further data, they could not determine if the shuttle had been damaged
seriously by the foam strike. Rocha made several attempts to get permission to have the Air Force take
photos. The Air Force was willing to get the photos. But it was told by the Mission Management Team
and by other NASA officials that it did not want further photographs. Rocha’s requests were rebuffed by
the Mission Management Team, the Flight Director for Landing, and NASA’s shuttle tile expert, Calvin
Schomburg. Whether such photos would have affected the shuttle’s ultimate fate is unknown, but in
retrospect NASA seems reckless not to have gotten them. (See Cabbage & Harwood, 2004, p. 134 and
elsewhere). “Fixing the messengers…….” Fixing the messengers instead of the problems is typical of
pathological organizations. Cover-ups and isolation of whistle-blowers are obviously not a monopoly
of the U.S. Air Force.
5.8.3 Public Relations and Local Fixes
Organizational inertia often interferes with learning. It makes many organizations respond to failure
primarily as a political problem. Failure to learn from the individual event can often take place when
failures are explained through public relations, or when the problem solved is seen as a personal defect
or a random glitch in the system. For instance, even though the Falklands air war was largely won by
the Royal Navy, public relations presented the victory as a triumph for the Royal Air Force (Ward, 1992,
pp. 337–351). The public relations campaign obscured many RAF failures, some of which should have
forced a reexamination of doctrine. Similarly, it has been argued that problems with Boeing 737–200s’
pitching-up needed more attention than the situation, even after the Potomac crash of an Air Florida jet
(Nance, 1986, pp. 265–279). Previously, Boeing had responded to the problem with local fixes, but without
the global reach that Boeing could easily have brought to bear. When Mr. Justice Moshansky was
investigating the Dryden, Ontario accident, legal counsel for both the carrier and the regulatory body
sought to limit the scope of the inquiry and its access to evidence. Fortunately, both these attempts were
resisted, and the inquiry had far-reaching effects (Maurino et al., 1995, Foreword).