Week 18: Resilience, Part Four (First Afternoon)

You are the Operations Manager of an airline with a regular route to a major city in a central African nation. Due to the length of this flight, your inbound crew hotels overnight, and the following day relieves the next inbound crew for the return flight. Civil unrest regularly interrupts access to fuel and other resources at this location. You continue operations in the face of this adversity, until one day strikes consume the city, forcing cancellation of the inbound flight and trapping your overnight crew in their hotel. What do you do?

After a lunch of frittatas and salad held in the sunny courtyard, we split in to two groups for the afternoon lectures. I chose the medicine-themed talks (instead of aviation), which were held in the large lecture hall next to the auditorium. The first presentation was by a Norwegian researcher who studies sensemaking in operating theaters.

Sensemaking is as it sounds: the process of making sense of and acting effectively in your environment. It is typically triggered by uncertainty and tends to be retrospective (as when we use the past to make sense of the present), but it can also be future-oriented, or prospective. During his study, the researcher observed teams of doctors, nurses and anesthesiologists as they prepared for and performed complex operations He found that before surgery, both doctors and nurses rehearsed not only the ‘master plan’ for the procedure, but also alternative courses the surgery could take, and the strategies to accommodate them. This seemed to enhance the performance of the teams (especially when communications supported a shared representation of events) and improve their ability to interpret unexpected events. He also observed that throughout a procedure the team made minor adjustments from the plan in order to keep the patient stable, and concluded that what on the outside can appear to uneventful can actually be highly dynamic. In the future, his research will focus on how these adjustments support resilient performance.

The prevailing view in many design and safety environments is that human performance is the primary threat to safe operations, and great effort is taken to minimize opportunities for us to adversely influence a system. In addition, incident and accident investigation tends to focus on the negative effects of the people involved, focussing on errors and violations the team or crew made along the way to the terminal event. The second lecturer was interested in rule violations as well, but not from this traditional perspective, but rather that they are evidence workers are active participants in the risk-management process. Thus his research investigates well-intentioned violations performed to produce desired outcomes.

Hospitals are complex places where a combination of routine and acute tasks are performed. The technology comes with one set of rules, procedures provide another set of rules, some tasks are performed so regularly they become second nature, while others are so unique they must be improvised on the fly, and all these must meet in a way that support the organization’s economic goals. This particular study sought to explore which rules were adhered to and when, and how people adjust to match actual work conditions, available resources, and situational constraints. The researchers observed that teams adapt work practices to the local environment, and participating nurses had limited awareness of which rules they were adhering to or violating. More importantly, the team observed that often rule violations resulted from attempts to reconcile conflicting goals, such as adapting an infusion rate to meet an administrator-imposed appointment schedule.

This might be a good point to touch upon the weather. When I hear Europe, I think snowy winters and mild summers, and the Julys I spent in the Netherlands and France had done nothing to dispel this perception. I had completely forgotten that the trade winds, those warm breezes that begin in Africa, flow to South America, and then back; and the Gulf Stream, those warm waters flowing northeast from the Caribbean have fueled Portuguese trade ships from the fourteenth century onward. This day these two phenomena had made landfall in all their glory: our lunch had been in the hot sun, and we had brought this inside to our ill-ventilated classroom. By the end of the first lecture it was steamy, and after the second I was downright glowy*. It was too much for me, and after a short break in the breezeway I retreated to the aviation lectures in the main, and more importantly adequately air-conditioned, auditorium. It was here I encountered the tale of the pilots stranded in central Africa and the Air Operations team tasked to help them.

For those not familiar with aviation, an Air Operations Control Center is a big room manned by flight dispatchers who, with support from other subject-matter experts, manage the schedule, manning, supply, and flow of an airline’s flights. The researcher, a German PhD student began the story in the AOCC of a major European airline, at the desk of the Nigeria Controller. It turns out that on this particular route, extending the overnight layover to two or more days in order to wait out lack of fuel or local unrest had become a somewhat ordinary event. What made this particular layover unusual was that, after this crew had been stranded for several days, unable to leave the hotel for security reasons, the airline’s Security Services had advised that local unrest was about to take a turn for the worse. It was only then, when the airline had to decide whether to evacuate the crew, that their Contingency Team was convened.

This airline’s Contingency Team consists of representatives from different departments: Management, Operations, Flight (cockpit crew), Inflight (cabin crew), Maintenance, Security Services, Outstations (locally-stationed maintenance and support personnel), Commercial (passenger interests) and Cargo. Up until now, these departments, independently and in small groups, had been able to accommodate the occasional (and increasingly frequent) flight cancellations at this location. Each group also had a stake in the near- to long-term suspension of scheduled operations. The presenting researcher had been embedded in the team’s meetings, and her observations focused on how ill-defined and often conflicting goals were prioritized as the situation evolved.

The airline’s first priority was the safety of the crew, and the first decision became whether and how to evacuate the pilots and cabin attendants. Evacuating the relief crew was a de-facto decision to cease operations to the location, an action that would carry a high economic cost. The airline had to balance these costs with the risk their personnel could be injured, kidnapped or killed, which, in addition to being a tragic loss, would harm the airline’s reputation as a safety leader. In the end the decision came quickly when another operator offered to evacuate the airline’s crew with their own.

The next question became if, when, and how to resume operations to Nigeria. The team had a range of options to choose from: ceasing operations entirely and rebooking existing customers on other airlines (high economic cost), resuming operations as before (high safety cost), or anything between (balancing safety, operational feasibility and economics). The Contingency Team quickly settled on an option that would allow them to maintain operations: adding an intermediate stop to the return flight to provide the outbound crew a more stable overnight location.

Once up and running, flights were scheduled up to three days in advance during which the Contingency Team monitored daily operations while the Planning Team investigated other options. Within two weeks the acute local unrest subsided, and the airline returned to normal operations. The process seemed to mirror what I had observed on my flight to DC: the airline took advantage of a short-term opportunity, replanned, took another opportunity, then replanned again, looking only at the decision immediately in front of them, with limited consideration of how a specific decision path might constrain future opportunities.

With that, it was time for our afternoon break.