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Learning to Fly: Risk Mitigation Lessons from a Professional Pilot

Julia Cooper
HOK's Director of Consulting Julia Cooper draws lessons from aviation risk management that can help organizations navigate challenges related to hybrid work and team dynamics.

As we continue to recover from the pandemic and return to “business as usual,” we would do well to acknowledge that our experiences over the past several years have been anything but usual. Admitting this fact to ourselves can be frightening. Yet, by doing so, we acknowledge that there are risks and that we might make mistakes. We understand that there are things we don’t know, but we are also aware that we don’t know what we don’t know. Additionally, there is the Dunning-Kruger Effect, which refers to being ignorant of one’s own ignorance. Consider how often you make decisions or recommendations based on a perception of certainty, only to realize later that you’ve made a mistake. This tendency is part of human nature.

Some people readily recognize their own ignorance, while others move through life thinking they have all the answers. Individuals in the latter group are often the quickest to share their certainty about the path forward. Most of us fall somewhere in between. We understand that we can’t make decisions about the future based solely on past experiences. Furthermore, the future won’t unfold in the exact same way as the past. Relying on guesswork or following what others are doing may not be the best approach to addressing your unique circumstances, situation, and people. Can we admit that we simply don’t know with certainty what the future will bring?

Raising awareness is a crucial step in reducing the risk associated with navigating uncharted territory. While there is abundant advice and well-informed written opinions on the “future of the workplace,” what if we broaden our perspective to include other industries that operate under constantly changing conditions, where risk is inherent in everyday operations? What existing processes and procedures have been developed to address risk mitigation and decision-making in these industries?

Anyone who knows a pilot will confirm that they love to tell stories, especially about flying. I know a pilot, my husband. While sitting around the fire pit with our neighbor recently, the conversation turned to speculation about the Kobe Bryant helicopter crash of 2020.

Nine people, including the NBA star and his daughter, lost their lives when the helicopter flew through the clouds into a hillside. The pilot chose to rely on visual flight rules rather than on instruments and was spatially disoriented as a result. Weather was a contributing factor but there were other decisions made that violated federal regulations and ignored proper training procedures. The National Transportation Safety Board (NTSB) concluded its investigation and released a report identifying pilot error as the primary cause of the crash.

Our conversation evolved into a discussion on “hazardous attitudes” and “operational pitfalls,” two core concepts of flight training. These essential aviation risk management lessons are fascinating and can be adapted to business challenges including hybrid working practices.

The Error Chain

A critical concept to consider is the “error chain,” a phenomenon characterized by a sequence of minor events or mistakes that align perfectly and directly contribute to a significant incident. In aviation, these links often originate from human-related factors, which is why pilot training places significant emphasis on cognitive abilities, behavior, and procedures.

In architecture, at the macro scale, a project team contributes to the final product over an extensive period. Each design step involves a set of technical considerations and decisions that are thoroughly checked. Project managers utilize checklist tools that review code and safety compliance throughout all building stages—planning, design and construction.

The same holds true at the micro scale, where people and space intersect in how and where we work. Consider the workplace. Every decision should link to leadership’s vision for the future within the context of the business. The physical environment can both facilitate or inhibit behavior in numerous ways. A solid workplace strategy considers multiple factors at the start of a project and connects decision making back to these in the planning and design phases.  Lighting, layout, air quality, daylight, color and texture are all links in the chain. If one of these is “broken”  the workplace doesn’t function as intended. Processes don’t run smoothly, people are less engaged, fatigue sets in, productivity dips. The correlation with business goals is direct.

Hazardous Attitudes

Attitude is our tendency to respond to people, situations, or events in a particular manner. When it comes to flying, attitude can have disastrous effects. Five attitudes have been found to be particularly hazardous. Recognizing each is a critical to a successful flight.

1. Anti-authority (Don’t tell me what to do!)

“The rules don’t apply to me. Rules are for the average pilot. I am better than that, so I can bend the rules.” This, in a nutshell, is how pilots with an anti-authority attitude might view certain situations. In aviation, this attitude has led to numerous fatalities.

In the business world, the anti-authority attitude also can be destructive and is frequently exhibited with managers who feel that they “know it all.” Many of these leaders have made their way into executive positions because of their self-confidence and willingness to forge ahead fearlessly. For them, the willingness to be open-minded during times of crises can be uncomfortable and feel vulnerable. Yet examination and introspection is exactly what is needed to address complex issues, particularly those concerning managing the people who are fundamental to achieving business goals.

2. Impulsivity (Do it quickly!)

Do it quickly, decide to do it quickly, and do it quickly without thinking ahead about the consequences.

In July 2000 a Concorde passenger jet bound for New York crashed shortly after taking off from Paris. The crash killed all 109 people on board and four people on the ground. In many ways, it was a classic aircraft accident, characterized by a sequence of events that ultimately led to the catastrophic crash.

During takeoff, a maintenance mishap caused the aircraft to deviate off course while traveling at a speed of 185 mph. A piece of metal struck and punctured a tire, resulting in a portion of the tire penetrating the underside of the wing. This impact ruptured the fuel tank, leading to a fire in one of the engines. Despite receiving no directive from the captain or first officer, the flight engineer instinctively initiated emergency procedures and shut off the engine. As a result, the aircraft never had a chance to reach the speed required for lift off. The engineer’s action proved unnecessary and disastrous. Not only was the fire external to the aircraft, thus somewhat contained, but shutting down the engine would not have extinguished the flames. In fact, turning off the engine only prevented the plane from reaching a point above the drag curve, at which point there may have had a chance to recover and make a safe landing.

This lesson can also relate back to the workplace. By slowing down decision-making and pausing to consider a range of options, we can adopt the strategy of “going slow to go fast” and develop a set of criteria for evaluating benefits and risks and making an informed decision. Engaging in a process of analysis, foundational to developing workplace strategies, connects your mission and business goals to people, culture and space.

3. Invulnerability (It won’t happen to me.)

The following thought process characterizes the “invulnerability” attitude: “I’ve completed the preflight checks and have done everything by the book, so there won’t be any issues. The weather I am seeing is different from what was forecast, but I’ve been methodical, so things should work out.”

The source of this attitude could be attributed to denial, an inability to think laterally or a lack of flexibility. The remedy is to recognize the weather has changed and, as a result, your plan and actions need to change, too.

Now, consider your company’s approach to hybrid working. The following attitude can be dangerous: “Everything has been working to date. We’ve supported our clients well, and getting back to business as usual is what is best for everyone. Five days a week, 9 to 5 hours. Sure, some of our employees are grumbling about the commute, or daycare, or the cost of gas, but these have always been surmountable issues in the past. We are a great company and world-renowned leaders in the field.”

But things have changed. What if these issues are insurmountable? And what if our competition is offering a level of flexibility that makes the insurmountable attainable? Onboarding and training new employees to replace those who leave for greener pastures is costly. There is also the institutional knowledge that is lost when a key employee resigns.

A little flexibility can go a long way. One way to mitigate this risk is to survey your employees to determine their must-haves vs. their nice-to-haves. Make decisions about hybridizing your workforce, office and processes based not only on what is best for the business and your clients, but also on your employees’ needs. Then develop a strategy for space usage to optimize your workplace and real estate. Leverage connective technologies that link your employees to one another and their work.

4. Macho-ism (Ego)

This is a tricky one. Machoism is associated with self-reliance, confidence and ability—all of which are valuable qualities in a pilot as well as an employee. However, when left unchecked, machoism can lead to aggressive behavior, where limits are exceeded and rules are broken.

In a business environment, where teamwork is crucial for success, such behavior can be detrimental. Every team member plays a valuable role. When one person behaves badly, the entire team suffers, putting the product or service at risk. This risk is amplified if the problematic behavior originates from the top levels of leadership.

Similarly, significant changes made without engaging employees can lead to feelings of neglect. Employees may feel their needs are not being considered, resulting in feels of alienation and marginalization. This can lead to disengagement and reduced productivity for both individuals and the team as a whole.

In some cases, machoism is overlooked or excused for talented and high-performing individuals. However, adopting a short-sighted view on machoism can lead to severe consequences for the business in the long run. These consequences can be more straightforward and even fatal in flight.

In aviation, Crew Resource Management (CRM) concepts were developed in response to machoism. CRM focuses on interpersonal communication, leadership and decision-making. It prioritizes cognitive skills over technical knowledge. These cognitive skills include the ability to gain and maintain situational awareness, problem-solving, and decision-making. In business, there is some overlap with emotional intelligence, which involves understanding, using, and managing emotions, effective communication, overcoming challenges, and resolving conflicts. The concept aims to promote a less authoritarian culture where crew members are encouraged to question captains if they observe mistakes in judgment or action, thereby enhancing safety. It represented a significant cultural shift for the industry but one that was well worth making.

The following flight emergencies illustrate the value of CRM. One had a fortunate outcome, the other did not.

In 2010 Qantas Flight 32 suffered an engine failure while flying over the Riau Islands in Indonesia. A turbine disc in the No. 2. engine disintegrated, causing extensive damage to the wing, fuel system, landing gear, flight controls, engine controls and a fire in a fuel tank. Five pilots were in the cockpit. Each helped monitor and assist the situation, including managing 100 aircraft emergency checklists. The aircraft made an emergency ground landing with no injuries to passengers or crew or people. Carey Edwards, author of the book “Airmanship,” wrote of the incident: “The crew’s performance, communications, leadership, teamwork, workload management, situation awareness, problem-solving, and decision-making resulted in no injuries to the 450 passengers and crew. QF32 will remain as one of the finest examples of airmanship in the history of aviation.”

In contrast, failure to follow CRM procedures was identified as a contributing factor to the 2009 crash of Air France flight 447 from Rio de Janeiro to Paris that killed all 228 people on board. Airspeed measurement inconsistencies during the flight confused the crew who put the aircraft into an aerodynamic stall from which it did not recover. Aviation journalist Jeff Wise reviewed the black box conversations just before the crash and wrote the following in an article for Popular Mechanics: “The men are utterly failing to engage in CRM. They are failing, essentially, to cooperate. It is not clear to either one of them who is responsible for what, or who is doing what.”

5. Resignation (What’s the use?)

Another reason it is important to recognize machoism and the value of CRM is the possibility that a pilot will accept an undesirable outcome, or wait for the situation to resolve itself, rather than keep working to find a solution. This can happen when a pilot interprets crew observations or questions as criticism and reacts emotionally. Other causes of resignation can be a feeling of bad luck or a lack of confidence in the ability to pinpoint a solution.

To combat resignation, whether in the cockpit or the office, it is important to realize that you can break the error chain, make better decisions, and effect change at any point. Everyone has a role in successful outcomes. If they believe that, risk is lessened. Remember that people are at the core of all work and should be at the center of decision-making in one form or another and at differing levels of influence. A human-centric workplace is one in which employees are empowered to make decisions as part of an inclusive and diverse community. When things are changing, we are wise to remember that people drive change. They need the right information at the right time, in the right way, before change can be fully realized. Change engagement—a targeted approach and process to transition individuals, teams, and organizations to a desired future state—is an integral part of any transformative process.

Operational Pressures and Pitfalls:

Here is where we come back to the Kobe Bryant flight.

Pilots, particularly those with considerable experience, always try to complete a flight as planned, please passengers, meet schedules, and generally demonstrate that they can be trusted to do their job well and keep passengers safe.

“Operational pressures” exist relative to the business of flying. Emphasis on efficiency, output, poorly designed workload policies, or a lack of an effective safety culture can play a factor in outcomes. Aeronautical decision-making involves navigating through classic behavioral traps into which people have been known to fall. These traps are called “operational pitfalls.”

The operational pressure Kobe’s pilot, Ara Zobayan, experienced would likely have been influenced by at least two—possibly three or more—operational pitfalls. This tragedy is a heartbreaking but excellent example of the error chain’s cause and effect.

Peer pressure is one pitfall. These are factors that affect decision-making. In this case, there might have been a psychological or psychosocial stressor associated with transporting a high-profile celebrity. A pilot can feel pressure to push limits that would normally be deemed unacceptable in order to please passengers. The flight was behind schedule due to weather, and the passengers were anxious to get where they were going.

Duck-under syndrome happens when a pilot is tempted to believe there is a margin of error in the environmental limits or procedures. This is subtly different from anti-authority and machoism, but it is still an attitude based on the psychology of justification. Pilots may tell themselves, “I set some limits, and now I accept I am below those limits.” Yet this attitude sets aside the built-in safety factors that account for unseen circumstances, weather deterioration or other factors that might require your focus. As a result, you’ve eliminated any buffer or margin of error.

In the end, the pilot was so task-focused on achieving the mission that he  failed to recognize contributing factors that would normally lead him to abandon the task. The pilot neglected to consider the regime of flight (speed, altitude and the geographical proximity of the rising terrain) and they did not have the autopilot ready to engage in the event of cloud penetration.

Risk assessment is only part of the equation. After determining the level of risk, the pilot needs to mitigate the risk. There are more than one ‘if only’ moments here. Sadly, the pilot could have taken several measures to reduce risk, including:

  • Waiting for the weather to improve
  • ‘Land and Live’ (an FAA campaign message to helicopter pilots)
  • Flying under instrument flight rules
  • Canceling the flight

From a business standpoint, there are many drivers and factors affecting decision-making about the workplace and real estate. No one company or organization will have the exact same challenges and how people respond to challenges and solutions will also differ.

Epilogue

At the beginning of this piece, I mentioned that increasing awareness is one step that can mitigate risk. I also acknowledged that there is no shortage of good advice and informed written opinion on the “future of the workplace.”

This article isn’t about recommending specific solutions. Rather, I am proposing that organizations mitigate risk by deploying a methodology to uncover quantitative data and qualitative information. The goal is to facilitate decision-making based on mission, vision and business goals. This approach will help organizations:

  • Explore degrees of employee mobility and hybrid working processes to assess the pros and cons of different approaches.
  • Consider accessibility and inclusivity at a deeper level and design for the extreme user. Acknowledge that a significant percentage of the population, and some of the most creative people, are neurodivergent and have different environmental sensitivities related to the workplace. In the right environment, they thrive and generate transformational ideas and inventive solutions.
  • Recognize that talent attraction and retention are major issues. Culture, compensation, and opportunities for advancement all play a role, but the workplace can provide powerful incentives to stay with or join an organization. If you aren’t providing the absolute best workplace, it is likely your competitors are.
  • Explore seamless and ubiquitous integrated technology that allows connectivity in and between the office and remote locations, supports user control and optimizes space-use analytics.

The future of work involves workplace processes, employee engagement and access to specialized equipment. Fortunately, determining the right approach to support hybrid working isn’t as great a risk as flying in poor weather at night on a tight schedule with the potential for an engine malfunction. Yet the process of decision-making about real estate should be based on sound principles and breaking the error chain at every point in the process.

Julia Cooper is HOK’s director of Consulting. A workplace strategist with more than 25 years of strategic planning and design experience, she understands how to use the work environment as a strategic tool to solve organizational challenges. Discover more about Julia and HOK’s Consulting group at hok.com/consulting

Photo: The author and her husband, Nigel Cooper, an FAA certified flight instructor and Sonoma County Sheriff’s Office search and rescue helicopter pilot.

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