Giving feedback to the supervisor: the risk of mitigation

• Captain, we’ve been waiting for a landing for over an hour and I have a feeling we’re running out of fuel.
• Beg your pardon?
• The fuel, Captain, according to the fuel gauge we have only a few minutes left. Shall I request an emergency landing?
• A few minutes?
• Maybe… We’re fallinggggggg!

What I have reported here is a conversation between the Captain and his second-in-command not too different from those recorded by the aircraft black box and found after an air crash.

This conversation is an example of mitigation: we use it when we want to

soften or minimise the meaning of our words
in order not to shock the listener’s sensitivity,
especially when we want to make feedback acceptable.

We use mitigation when we want to be nice, when we are embarrassed, or when we are in deference to authority.

If, for example, you need your boss to do something for you by Monday, you are unlikely to say “I need it by Monday”.

More likely your words will be: “If you’re busy, don’t worry about it; but if you happen to look at it over the weekend, I’d appreciate it“.

Well,

mitigation is one of the most important causes of air crashes!

Let’s see why.

Air crashes never happen as you see in the movies, with violent and unexpected phenomena, because jets are highly reliable; air accidents are mainly the result of a series of small difficulties and seemingly insignificant malfunctions.

Here are some recurring aspects of a typical aviation accident:

• the weather conditions are unfavourable or such that the pilot is more concerned than usual;
• the plane is late, and the pilot is in a hurry;
• in more than half of the accidents, the captain has been awake for more than 12 hours; so he is tired and his reflexes are not ready;
• in just under half of all accidents, the two pilots have never flown together;
• in more than 50% of all air crashes, the Captain drives the aircraft.

A study by the NTSB (National Transportation Safety Board, independent U.S. government investigative agency responsible for civil transportation accident investigation) reports that

an air disaster is caused by 7 sequential human errors.

One of the pilots makes a mistake, which in itself is not particularly serious. After that one of the two pilots makes another, but even the combination of the two mistakes does not lead to a catastrophe. Then they make a third mistake, then another and another and another and another and another; it is their combination that leads to disaster.

The seven errors are rarely due to a lack of knowledge, as the pilot rarely has to deal with difficult situations that he is unable to cope with.

The mistakes that cause aircraft to crash invariably occur in communication and teamwork:

• a pilot knows something important and for some reason does not communicate it to the co-pilot;
• one pilot makes a mistake and the other doesn’t realise it;
• the two pilots fail to cooperate in dealing with a complex situation;
• the flight deck is designed so that two people operate it and everything runs smoothly when one pilot is controlling the other and the two share the tasks: when this does not happen, trouble invariably arises;
• flights are safer when they are driven by two people working together rather than one person being in command and the other just standing by to take over if the captain is unable to do so.

Interesting, isn’t it? But the best is yet to come.

Let’s go back to the point that in more than 50% of all air crashes, it is the Captain who drives the aircraft.

Below are some cases where the second pilot warned the captain of the upcoming danger but was either not given proper attention or the communication was compromised by the mitigation (or otherwise was not effective):

• Tenerife, Canary Islands, 1977. A KLM Boeing 747 collides with a Pan Am 747 which was taxiing on the runway: 583 dead.
• Washington, USA, 1982. The Air Florida flight crashes into the 14th Street Bridge over the Potomac River: 78 deaths.
• Guam, South Korea, 1997. A Korean Air Boeing 747 crashes into a mountain: 228 of the 254 passengers die.
• New York, USA, 1990. A Colombian Avianca Boeing 707 crashes on a private estate mistaken for an airstrip: 73 of 158 passengers die.

Why is a plane crash more likely when the Captain is in charge?

Shouldn’t the opposite be true?

If the Captain is driving and the co-pilot makes a mistake, the Captain will have no hesitation in commanding an action to avoid the danger, and the co-pilot will obey.

If the roles are reversed, mitigation takes place: communication is less direct, the time needed to perceive the danger is longer, and the one to take the necessary action to avoid disaster is even longer.

If we look at the previous conversation in the light of these considerations, the danger of mitigation becomes clear.

What have commercial airlines done to combat mitigation?

First of all, there has been a general awareness of its existence and the need to take action, although not all companies have adopted the same criteria for combating it.

Here are some of the most common actions:

• the Captain and his co-pilot are calling each other by name;
• the training consists of encouraging the co-pilot to give clear and unambiguous feedback;
• the Captain is ready to accept the feedback;
• in extreme cases, where the Captain appears not to be listening to the co-pilot’s recommendations, the co-pilot is obliged to take command.

Having tackled mitigation vigorously has led airlines to substantially reduce the number of air accidents over the last 20 years.

What about businesses?

Do they also experience a “mitigation effect”, in your opinion?

And if so, how much does it affect business results?