Risk management practices in the cockpit

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David Passenier	VU Amsterdam

In this project we investigate how real-time risk management practices are entwined with the social construction of risk in the work of civil aviation pilots. The work of pilots is special because, unlike in most cases where risks are managed retrospectively, such as in accident investigations, or prospectively, such as when identifying potential harm of products, pilots often have to manage risks real-time. During real-time risk management pilots are occasionally forced to deviate from procedures in order to react to unforeseen events.

The dominant approach to risk management views human deviance as inherently dangerous and thus revolves around questions how to prevent the ‘normalisation’ of deviance and manage compliance with rules and regulations. Based on a qualitative, in-depth study of commercial airline pilots’ real-time risk management, we suggest that, instead, deviance plays an important and positive role in the human contribution to risk management. Pilots routinely deviate from procedures, and rather than seeing that as a problem, we analyse how this enables them to manage risks real-time.

Another aspect of real-time risk management is prospective sensemaking. We observed commercial airline pilots handling regular surprise and ambiguity in operational flights and in flight simulation sessions. Unique improvisational action trajectories emerged in each prospective sensemaking episode that explained the quality of prospective sensemaking, regardless of the outcome of the sensemaking episode. Prospective sensemaking is critical in routine settings because this is when pilots experience fluctuating workloads and become experiential experts in dealing with equivocal situations. 

We aim to shed light on prospective sensemaking as it emerges real-time in regular operational events. During flight operations pilots are confronted with equivocal, time- and resource-pressured situations that require them to formulate and assess future action plans by vocalizing impressions and feelings triggered by the events, diagnose the situation, prioritizing pressing issues, and projecting possible action trajectories. Our understanding of these prospective sensemaking episodes is derived from observations of commercial airline pilots in operational flights and in flight simulation sessions. Our analysis details the unique improvisational action trajectories in each prospective sensemaking episode pilots engaged in, when fluctuating workloads required them to deal with equivocal situations.

In this project we contribute to literature on sensemaking in high reliability organizations by arguing that generic attitudes or organizational capabilities, such as mindfulness, and deference to expertise, do not sufficiently explain high reliability. Instead, we argue that prospective sensemaking processes explain more accurately how and why pilots are able to construct safety critical processes in flight through adequate future directed projections.